First Floor, 13 South Terrace
Fremantle Western Australia

PO Box 1555
Fremantle Western Australia 6959

p +618 9336 4544
f +618 9336 4463
admin@kulcha.com.au www.kulcha.com.au

Multicultural Arts
of Western Australia

Multicultural Arts of WA
holds the following Liquor Licence
Licence #: 6230043885
Special Facility Licence

Kulcha Sponsors

If you prefer, you can download and print the membership form in pdf format by here.

KULCHA Membership Form

Title

Family Name

Given Names

Organisation

For family or group membership, please provide a name for the second card.

Second name

Address

Town/
Suburb

Postcode

Phone (H)

Phone (W)

FAX

Cultural
Heritage

Profession/
Occupation

Interests

Membership

New Renewal

class of membership

I would also like to add a donation
$
all donations over $2 are tax deductable

I would like to support Kulcha
In kind sponsorship volunteer work

Please enter the five digit verification code above
(five strong digits only)

choose payment option (1,2 or 3)

1 Email credit card details

Card Type
Visa Mastercard Bankcard
Amount $
Card Number
Expiry Date /
Name on Card

Signed
______________________________________
(if by fax or post)

2 Credit card details by fax or post

Print this form on your computer printer
Submit your application form here and now
Write your credit card details
onto your printed form
Fax it to Kulcha (08) 9336 4544
OR
Post it to Kulcha
PO Box 1555
Fremantle WA 6959

3 Payment by cheque