Associate Membership Form - Conservation Council ACT Region

Name of Organisation/Corporation(Required)

State whether an Organisation (ie member-based) or a company or corporation

Organisation (member based)

Company

Corporation

Name of principal/director

First Last

Name of primary contact person

First Last

Job title of primary contact person

Website

Phone

Email

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Publicly identified purpose or purposes of applicant organisation (consistent with objectives of the Conservation Council ACT Region)

Objectives of the Conservation Council ACT Region (the association) 1) The association’s objectives are to: a) maintain, preserve and enhance the quality of thenatural, urban and rural environment and the integrity of ecological systems and processes; b) preserve and safeguard the natural, Aboriginal and non-Aboriginal heritage; and c) promote community understanding of the common responsibility for the maintenance of a healthy and sustainable environment, on which all life ultimately depends.

Insert extract from and links to relevant documentation

Drop files here or

Max. file size: 49 MB.

With relevance to the publicly identified purpose of applicant organisation.

Evidence of the applicant’s commitment to the purpose or purposes as identified above and demonstrated by its actions

Declaration

I [insert name of principal] declare the above information to be a true statement of the conservation or environmental protection purpose or purposes and operations of [insert name of the organisation] and actions to support this.

Signed By

Principal/Director

Signature

Date

Supported By

On behalf of a current financial member organisation of the Conservation Council ACT Region

Signature

Date

Additional Contact

First Last

If relevant

Phone

Email

Thank you for your application

This form will be forwarded to our Board Secretary and Executive Director for consideration and approval. We will be in contact shortly.

Once advised of the annual fee, payment can be made via one of four options:

1. Electronic transfer payment to: Bank Australia Account Name: CONSERVATION COUNCIL ACT REGION BSB: 313 140, Account No: 12056682 Please state your organisation’s name as a banking reference for us 2. Cheque made out to Conservation Council ACT Region and mailed to: Conservation Council ACT Region, GPO Box 544 Canberra 2601 3. Credit card payment over the phone - our office on 02 6229 3200 4. Cash or cheque payment at our office: Lena Karmel Lodge Building, 14/26 Barry Drive, Canberra (Please call ahead to ensure office is staffed.) Please retain a copy of your completed form as a receipt. Thank you

Name

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Associate Member Application Form (Organisations and Corporations)

Thank you for your application

Once advised of the annual fee, payment can be made via one of four options: