Change of Club/Group Details » Shire of Kellerberrin

Club / Committee/ Group*

Postal Address

Street Address:*

City:*

State:*

Post Code:*

Country:*

Contact Phone Number*

Email*

Contact Name*

Action*

Office Bearers to be Removed

Office Bearers to be Added

List the Office Bearers to be added with position, full name, email, phone number (Changes only need to be indicated - anyone continuing in the same position doesn't need to be mentioned)

Declaration*

I declare that the information provided by me on the above form is true and correct to the best of my knowledge and belief.

Full Name*

Certificate of Currency

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