Membership Form: Individual Membership Application Membership Form: Individual Membership Application 1st April 2019 to 31st March 2020 Please complete this form to renew your membership of Queensland Quilters. If you are human, leave this field blank. Title * MRS MS MISS MR DR OtherOther Name * First Name Last * Last Name Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Northern Mariana Islands Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe Country Email * Please enter your email address Membership Number Phone Number Type Number including area code, without any spaces: 0712345678 Mobile Type all numbers without spaces: 0421345678 Art Union Tickets Each member will be sent Art Union tickets to sell (each book has 10 tickets at $2 each Number of Books you would like to sell Membership Fees: Full year Membership to 31st March 2020 Members * Renewal Member: $50 Subscription to 31 March 2020 New and Non-Financial Member: $55 Subscription to 31 March 2020 Payment Amount $ Payment You can make payment by Direct Deposit to Queensland Quilters OR by Credit Card Direct Deposit Name of Account: Queensland Quilters Inc BSB: 034-002 Account Number: 768617 Please include your last name and membership number as the payment reference. Credit Card Please contact Verna Hunt with your credit card details. Mobile: 0409 062 485 Signature * Clear Date * Submit
