STATE MINE HERITAGE PARK & RAILWAY
THE CITY OF GREATER LITHGOW MINING MUSEUM INC
Incorporation No. Y11231-17
Museum Site:

State Mine Gully Road
Lithgow N.S.W.
(off Atkinson Street)

Site Phone: (02) 6353 1513
Site Fax: (02) 6353 1185

 All Correspondence To:

The Secretary
P.O. Box 617
Lithgow N.S.W. 2790
APPLICATION FOR MEMBERSHIP
Memberships fall due on July 1 each year

Annual Membership is $22.00 Ordinary, $11.00 Concession and Student
$5.50 Junior

Complete this form and mail with your subscription to:
The Secretary, PO Box 617, Lithgow, NSW 2790
I _______________________________________________ Birthdate:____/____/____
(PRINT full name)


Of, _________________________________________________________ Postcode: __________
(PRINT address)



Phone No.: _______________Email: _________________ Occupation: _____________________

Hereby apply to become a member of the above named incorporated association.



Concession details (where applicable):

__________________________________I enclose $__________
(Concession No/School)


I will, on occasions, bring my car onto site, the Registration No. is _____________

In the event of my admission as a member I agree to be bound by the rules of the
association and any determinations of the Board of Management, as made from
time to time.



_______________________________ Date____/____/____
(signature of applicant)


_________________________________ ______________________________
(name of nominating/witnessing member) (signature)