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Get involved » Stirling Alliance Community Leadership Group Membership Form

Stirling Alliance Community Leadership Group Membership Form

1. Name:

2. Please select your title:

Other title?:

3. Organisation's name (if applicable):

4. Email address:

5. Postal address:

6. Phone number (include area code if outside Western Australia):

7. Fax number:

8. What is your preferred method of contact?:

9. Which one of these best describes you?:

10. If none of the above options are relevant, please describe yourself:

11. If you work in the area, please select an option which best relates to you:

12. Which precinct would you consider yourself involved with most?:

13. Please describe your involvement in this precinct:

14. What is your area of interest?:

15. Please add your area of interest if not listed above:

16. Do you wish to be more involved in the Project/Alliance?

17. If you wish to be more involved, please select which mailling lists you would like to subscribe to:

18. Are there any other ways you would like to be involved?:

19. Please provide any additional comments prior to submitting this form: