First name:____________________ Last name:_________________________________
Address:________________________________________________________________
City/Town:____________________ Post Code:_______ State:_______
Country:___________________ Email:_________________________________________
Date:____________ Tel:__________________ Fax:_________________
I would like to pay Family Membership of $40 or
Amount $____________
I would like to pay Single Membership of $35 or
Amount $____________
I would like to pay Student/Pensioner Membership of $25 or
Amount $____________
I would like to make a donation for the work of the White Eagle Lodge.
Amount $____________
Australian Cheque, Australian Money Order or International Money Order
Please circle one
Please make payable to White Eagle Lodge of Australia
Please circle the card type: Visa Mastercard
Card Number:__ __ __ __/__ __ __ __/__ __ __ __/__ __ __ __ Expiry Date:____/____
CCV No.:_______________ (last three numbers on back of card where you sign)
Card holder name:_____________________________________
Card holder signature:________________________________
Post or Fax to:
White Eagle Lodge - PO Box 225, MALENY, 4552, QLD, Australia.
Tel: + 61 (0)7 5494 4397 Fax: + 61 (0)7 5494 4169