ADELAIDE HIGH SCHOOL OLD SCHOLARS ASSOCIATION INC C/O ADELAIDE HIGH SCHOOL, WEST TERRACE, ADELAIDE SA 5000 2015 MEMBERSHIP & DINNER PAYMENT FORM Name:______________________________________________________________ Maiden Name (if applicable) ___________________________________________ Years at AHS (eg 1975 - 1979) __________________________________________ Grades completed at AHS (eg Yr 8-12) ___________________________________ PLEASE TICK AS MANY AS APPLY $ I am a Life Member of AHSOSA NIL I am a 2014 graduate and wish to take out AHSOSA membership NIL I wish to renew/take out membership of AHSOSA and enclose my subscription of $25. $ Address ____________________________________________________________ I wish to make a donation to the continuation of the annual AHSOSA prizes at Speech Day $ Suburb ___________________________________________ I wish to make a donation to the AH Campbell Memorial Prize $ I wish to pay for _____ Annual Dinner tickets at $60 each for Financial Members $ I wish to pay for _____ Annual Dinner tickets at $70 each for Non-Members $ I wish to make a donation to the AHS Cricket Program $ I wish to make a donation to the AHS Rowing Program $ CONTACT DETAILS Postcode _______ Phone _______________________ Email ________________________________ 2015 ANNUAL DINNER DETAILS – Friday, 26 June 2015 Pavilion on the Park, Veale Gardens, Cnr South Tce & Peacock Rd, Adelaide Name of Table Captain ________________________________________________ Please list names of people being paid for ________________________________ ___________________________________________________________________ TOTAL AMOUNT PAYABLE ___________________________________________________________________ I have enclosed a cheque/money order for $ __________ Please list names of people to be seated with Table Captain _________________ Please deduct $ _______________ from my credit / debit card. ___________________________________________________________________ Card Holder name ___________________________________________________ ___________________________________________________________________ Card number _______________________________________________________ List of people you’d like to be seated with ________________________________ Expiry Date ________________________________________________________ ___________________________________________________________________ Signature __________________________________________________________ ___________________________________________________________________ Cheques made payable to Adelaide High School Old Scholars Association c/ - Adelaide High School, West Terrace, Adelaide 5000 ___________________________________________________________________ $