CLW Postal Form for Payment by Mail

Name:

User name: (1st choice)

User name: (2nd choice)

Password:

Occupation/Position:                                       Age:

Telephone (to confirm details if required)

Email Address where your Username, Password, E-News will be sent to:

Payment Method:  Cheque (    )   Money Order (   )   Credit Card by post (   )

Credit Card - Card Type: Visa (    ) Mastercard (      ) Bankcard (    )

Card Number:        _  _  _  _      _  _  _  _      _  _  _  _      _  _  _  _

Expiry:            Month:                           Year: 20

Name on Card:

How did you find out about the Centre? (please circle)

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