Independent Nations Social Organization

694 Mersey Road North, Osborne SA 5017 GPO Box 2472 Adelaide SA 5001
Phone: 01737150401 Fax: (08) 8348 7001
Email: insocialorg@.com

MEMBERSHIP FORM

Date Joined
Surname Given Names
ASC

Payroll No. Department Work Phone Email Address

Previous Member of Social Club?

(Please circle)
YES NO

Children

Name Birth date Sex (M/F)

I hereby apply to join the ASC Social Club Inc. (“Club”) and will pay, in advance, a minimum of the
declared 6 monthly rate of $77.00 (including GST), or as set by the ASC Social Club Committee, until
I resign in writing from the Social Club. I agree to abide by the Club’s Constitution and Code of
Conduct.

Member’s
Date
Signature
On completion, please forward this form to the ASC Social Club Membership Officer, care of the
above address, with the required payment (6 months $77.00, 12 months $154.00, inclusive of GST).
EFT payment details:
BSB: 035 031 Account No: 131433 Account Name: ASC Social Club Inc

For ASC Social Club Use

Created in Created in
Membership No. Date Initials
Database Website

Mailing List Date Initials Date card issued

ASC Social Club Form 002 – Rev 04.1

March 2014