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Perth Modernian Society Membership Form
Roberts Road Subiaco WA 6008
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New Membership
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Cheque for $100 mailed to PMS at Above Address:
Family Name Now:
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Family Name at School:
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Given Names:
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Title (eg. Mr, Dr):
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Postal Address Line 2:
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Country (If not Australia):
Home Phone:
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Mobile Phone:
Email Address:
Partner's/Spouse's Name:
Year Attended PMS Yr1(8):
Year Attended PMS Yr2(9):
Year Attended PMS Yr3(10):
Year Attended PMS Yr4(11):
Year Attended PMS Yr5(12):
Years on Staff 1st Appointment:
Years on Staff 2nd Appointment:
Years on Staff 3rd Appointment:
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