Your Information

First Name

Last Name

Street Address Line 1

Street Address Line 2

City

Postcode

Email

Mobile number

Note: mmvllen Inc. only has individual membership, no organisational membership.

Optional

Job title

Organisation

Work phone number

Signature

I hereby apply to become a member of Maribyrnong & Moonee Valley LLEN Incorporated.

If admitted as a member, I agree to be bound by the Rules of the Association in place and as updated in the future.

(please tick to agree)

Name of applicant

Date

Note: If your membership is approved by the board you will be added to mmvllen’s e-newsletter list unless you specifically request not to be added to this distribution list.