West Gippsland Inc. Membership Form Name Your Name: * Your Email: * Your Contact Number: * Optional Second Email: Postal Address: (inc. postcode and state) Total Amount please select 12 month Membership $50 Lifetime Membership $300 Visitor with Financial Member Only Renew Membership Payment Options: Please Select Visa or Mastercard Cheque or Money Order Direct Debit Credit Card Number: Expiry Date Name on Card: Please type in this box any requests, comments or questions you may have. Post to: West Gippsland Inc. 10 Little Acre Close, Langwarrin Vic, 3910. Or Fax your form to (03) 9776 6798 or Telephone 0428 534 102. Or Direct Debit: Account Name: West Gippsland Inc. BSB: 033 138 Account Number: 571 827