Coolgardie Gem and Mineral Club Inc.
Membership Form

Fees are $15 renewable on July 1/ 2009 (map package is an additional $8 + $5 postage)

Name...................................................................................................

Address ................................................................................................ 

................................................................................................ 

Post Code............................ 

Phone ....................................................

Email ...................................................                                                                  .        ( Please give your email if you wish to receive the latest news updates and activities)

Amount enclosed  ............................ 

If my application is accepted, I agree to be bound by the rules of the Association.
A copy of the rules can be obtained from the secretary.

Signature:………………………………………….   Date:…………………………………………………

Please hand in form to Ronnie Potter at the Gem Club (Old firebrigade Shed , Sylvester St,  or post with cheque or money order to:

Coolgardie Gem Club
PO box 34 Coolgardie 6429
Phone 90267194  or 90266169