ICAG Membership Form
Membership Form for Ipswich Climate Action Group Incorporated. 
($20 annual Fee, extra donations gratefully received). Please deposit fees to
Bendigo Bank BSB: 633000 Account Number: 204556591
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Email *
Name *
Address: *
Phone Number  *
Date Joined *
MM
/
DD
/
YYYY
Date membership paid *
MM
/
DD
/
YYYY
Donated Contribution Amount (if applicable)
Are you human? What does the C stand for in ICAG?
(use lower case)
 *
A copy of your responses will be emailed to the address you provided.
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