MEMBERSHIP FORM

Fields marked with an asterisk * must be completed before the form will submit.

Do you wish to join Southbroom Ratepayers Association or Southbroom Conservancy, or will you be supporting both initiatives?

Association:  Select preference here Southbroom Ratepayers Southbroom Conservancy Both *

The annual subscription for Southbroom Ratepayers is R100.

Will you be adding a donation to your Ratepayers subscription?

        Yes - Type the amount  No

Southbroom Conservancy has different types of membership.  Which category would you prefer?  (Note: If you do not wish to support the Conservancy, select "Ratepayers Association only")

Membership Type:  Select membership type here Ratepayer Association only Family - Annual - R200-00 Family - 5-years - R1000-00 Family - Life - R2,000-00 Corporate - Annual - R500-00 Corporate - Life - R5,000-00 *

Tell us how to get in touch with you, and your address in Southbroom.  Fields marked with an asterisk ( * ) are required fields:

Name	*
Email	*
Landline
Cellular
FAX
Lot No.	*
Street	*

Thank you for your support.