Membership application

Complete this form and deposit your payment to:

Account name: Canberra Queanbeyan Poultry Club
BSB: 805 022
Account No: 03388931

Please use your full name as the reference. Fields marked with * must be completed.

MY DETAILS

MY CONTACT DETAILS

MEMBERSHIP TYPE

A BIT ABOUT ME

MY INTERESTS

Select all the boxes that apply to you.

Thank you. Click SUBMIT to send your application. Please remember to add your name as a reference
when you deposit your payment so we can verify your membership.