Q Club Membership Application Form - Canberra

Membership Application
Membership Category
1 year
2 years
Individual
$113
$183
Concession
$59
$105
Family (2 adults and up to 3 children)
$160
$260
Single Parent Family (1 adult and up to 3 children)
$130
$215
Additional Child (Must be part of a Family/Single Parent Family)
$17
$28
$5
Additional Card
Personal Details (Please complete all details)
Title
Mr
Mrs
Miss
Ms
Other
Name
Address
Suburb
State
Telephone (H)
Postcode
(M)
(W)
Email
Please print the name(s) of the individual(s) requiring membership:
Adult 2
M
F
Child 1
D.O.B
DD/MM/YYYY
M
F
Child 2
D.O.B
DD/MM/YYYY
M
F
Child 3
D.O.B
DD/MM/YYYY
M
F
Please note: family includes 2 adults and 3 children. Additional children are required to pay an extra fee (see prices above) — children are 4–16 years.
Child 4
D.O.B
DD/MM/YYYY
M
F
Child 5
D.O.B
DD/MM/YYYY
M
F
Gift Membership (please select membership choice below)
Please send membership to me
Membership to start immediately
Please send to new member (above)
Membership to start
DD
/
MM
/
YYYY
Buyer’s Name
Address
Suburb
State
Telephone (H)
Postcode
(M)
(W)
Email
Payment Details
0.00
I am paying the amount of $
Mastercard
Visa
by:
Amex
Cheque
Money Order
Cheque or money order should be made payable to:
Questacon – The National Science and Technology Centre
Please send to:
Card Holder’s Name
Credit Card Number:
Replied Paid No 002
/
/
Q Club, Questacon
/
PO Box 5322
Signature
Expiry
/
Kingston ACT 2604
King Edward Terrace, Canberra
T 02 6270 2874
F 02 6213 7254
E [email protected]
www.questacon.edu.au
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