Application for membership of
'Spaced Out' Inc
(A0039311B  -  ABN 36007859611)
Spaced Out, P.O. Box 12033, A'Beckett Street RP, Melbourne, Victoria 8006, AUSTRALIA
Name :

Address :

Phone :

Email :

I apply for membership of 'Spaced Out'. In the event of my admission as a member, I agree to be bound by the rules of this Association. I also agree to be bound by the privacy policy of the Association which states that any member can access their own details from the membership register at any time but that due to the potentially sensitive nature of the club membership information, all other access to membership information needs to be via the Secretary.

(Select your choice below)

☐   I am happy to receive all correspondence electronically.
☐   I prefer to receive my correspondence through Australia Post

  (Please tick and sign below.)

☐   I declare that I am over 18 years of age

Signed :

Date :

or
☐   If under 18 years of age, membership can only be considered with the written consent of parents or guardians.

If under 18, please ensure the following is signed :

I, _____________________________ being the parent, guardian or trusted adult friend of

_________________________________________  give my consent for their membership of Spaced Out. I accept responsibility for their involvement in this organisation.

Signed :

Date :

How did you find out about 'Spaced Out'?
 

What are your particular science fiction interests?



Details of Annual Subscription Fees



  Fee                                                                                  Amount


Annual subscription fee                                                       $15 standard and $10 concession

Please send cheque or money order made payable to Spaced Out Inc. and post to Spaced Out, P O Box 12033, A'Beckett Street RP, Melbourne, Victoria 8006, AUSTRALIA.