PSV Membership Application Form

Membership Application

To apply for membership please complete all questions.
Who Should use this form:

- A Muslim who wants to become a PSV member;

Note: This form is to be submitted online once completed. Once submitted, your application form will be processed for approval in PSV's committee meeting and you will be notified of the outcome via Email.
Full Name*

PrefixFirst NameMiddle NameLast Name
Year of Birth*
Are you a Muslim of Shia - Ithna Ashari Faith?*

YesNo
Marital Status*

SingleMarried
Employment Status*

Full timePart timeUnemployedPensionerStudent
Membership Fee (AUD)
Per Annum
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Home Number

Area CodePhone Number
Cellular Number*
Are you a shia Ithna Asheri Muslim?*

YesNo
Click if you would you like to be included in PSV email distribution list?
References

Please provide two references of persons who are PSV members and can confirm your suitability for PSV Membership
1. Full Name*

First NameMiddle NameLast Name
Mobile Number*
2. Full Name *

First NameMiddle NameLast Name
Mobile Number*
I declare that the information provided in this form is correct to the best of my knowledge and that I am above 18 years of age & as such eligible for PSV membership as per PSV Constitution. I also declare that I will abide by the PSV constitution as a whole in its entirety. I will keep the PSV aware of any changes to the information provided in this form.*

Yes
Payment Options

Bank TransferCashPayPal
Bank Transfer: (Preferred)

Account Name: Panjtan Society of Victoria

BSB: 033-107

Account: 130164

Bank: Westpac Banking Corporation

Please email the transfer/remittance receipt to treasurer@panjtan.org.au once the payment is completed
Cash Payment:

To arrange the payment please contact PSV Treasurer at treasurer@panjtan.org.au
PayPal:

You can choose to pay via PayPal using your PayPal account, Credit/Debit card.
Membership Fee Payable (AUD)
This amount includes $10 joining fee.
Membership Fee Payable

prevnext( X )
AUDMembership Fee (Includes $10 joining Fee)
Date*

DayMonthYear
Date
Should be Empty:

Membership Application

References