Contact Details

I am an existing member and my contact information has not changed.

Contact Name *

Address *

Contact No. *

Email Address *

I would like to receive Gallery News via email.

Membership Details

First Family Member

Enter details of the person/s you are purchasing this membership for.

Enter details as they will appear on membership.

Title *

Enter 'other' title *

Full Name *

Second Family Member

Second Family Member Title *

Enter 'other' title of second family member *

Second Family Member Full Name *

Do you wish to add a third family member? *

Third Family Member

Third Family Member Title *

Enter 'other' title of third family member *

Third Family Member Full Name *

Do you wish to add a fourth family member? *

Fourth Family Member

Fourth Family Member Title *

Enter 'other' title of fourth family member *

Fourth Family Member Full Name *

You have reached the limit of family members that can be added - if you require additional members please contact the Gippsland Art Gallery directly.

Donation

Would you like to make a donation to Friends of the Gallery? *

Please specify amount *

Payment

Payment may be made in person at the Gippsland Art Gallery - simply show the staff member a copy of the confirmation email that will be sent upon completion of this form.

Acknowledgement

I acknowledge the Gippsland Art Gallery Privacy Statement. *

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