MEMBERSHIP APPLICATION
NOMINATION PAPER
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MEMBERSHIP APPLICATION NOMINATION PAPER |
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(tick one) |
MEMBER |
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CORPORATE MEMBER |
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COUNTRY/RETIRED |
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STUDENT |
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( A one-off Joining Fee of $50.00 is payable) |
$ 50.00 HEREWITH |
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| ............................................................................................. | ............................................................................................. | ||
| Given names | Surname | ||
| Title (circle) Prof / Dr / Mr / Mrs / Miss / Ms | |||
| Degrees and Decorations .......................................................................... ............................................................................... | |||
| Address (for mail) ........................................................... ..................................................................................................... | |||
| .............................................................. .............................................................................................. | |||
| email ............................................................................................................................................................................................. | |||
| ................................................................................................................................. Postcode .................................... | |||
| Phone: ............................................................................... (B) ................................................................................... (H) | |||
| Profession: ............................................................................... Position: ................................................................................... | |||
| Employed by: .................................................................. | |||
| Signature: ............................................................................... Date of Birth: .........../ ........./ ......... (for statistical purposes) | |||
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| Proposed by: ............................................................... Member’s Name: .............................................................................. | |||
| Seconded by: ................................................................. Member’s Name: ............................................................................ | |||
| Nominated: ............../............../ 200................ Elected: ............/............./ 200................ | |||
| Register: ........../.........../ 200................ | |||
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ABN 62 145 872 663 The Royal Society of Victoria Inc, 9 Victoria Street, Melbourne, Victoria, Australia 3000 Registered No. A 9576 Telephone (03) 9663 5259 Facsimile (03) 9663 2301 www.sciencevictoria.org.au email: admin@sciencevictoria.org.au |
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