I wish to

Join

Re-join -- My old membership number was:
-- I would also like to receive the Contempo e-newsletter. More info

Buy a gift membership -- Gift card message should read:

Art Gallery Society membership

(includes GST and registration fee)
Three-year membership fees are non-refundable.

1. Mr / Ms / Mrs / Dr (please circle) or Other:
Name(s):
(Please include given name)

Date of birth: / /

2. Mr / Ms / Mrs / Dr (please circle) or Other:
Name(s):
(Please include given name)

Date of birth: / /

Address:
Suburb:   State:   Postcode:

Phone: Mobile:

Email address:

Gift Recipient Details (if applicable)

1. Mr / Ms / Mrs / Dr (please circle) or Other:
Name(s):
2. Mr / Ms / Mrs / Dr (please circle) or Other:
Name(s):
(Please include given names)

Address:
Suburb:   State:   Postcode:

Phone: Mobile:

Email address:

Date of birth: / /

Please send initial gift pack: to Purchaser to Recipient
By / /
(Please allow up to 14 days for delivery or call (02) 9225 1878 for urgent gifts.)

Please send future renewals: to Purchaser to Recipient

My Payment Details

You may send a cheque made out to the Art Gallery Society of NSW, OR pay by Credit Card - please fill in your card details below.
To make next year's renewal easy and receive a one-off $10 discount, opt for our Automatic Direct Debit Renewal. Simply deduct $10 from the total, tick 'YES' and sign the Automatic Direct Debit authorisation at the bottom of this page (only for Automatic Direct Debit).

Total payment: $

Payment type: Cheque Credit card

Please charge my: 
Mastercard Visa American Express

Card Number:

Expiry Date:

Card name:

Signature of Cardholder: __________________________________

Date:

YES, I __________________________________ (signature) authorise for all future renewals to be charged as they fall due to the credit card on this form. (I may cancel this agreement at any time.)
NOTE: Direct Debit is not available for Student Membership -- Full time ID must be proved at each renewal time.