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COUNTRY CITY CONTACTS
Please write this Form in English if possible
the following Off - line & On - line / e - Commerce, Application Form(s), best printed with Portrait Page Setup Margins ALL 6 mm ( Millimeters ) &
View text size Smallest, & Edit / Format Font size Regular 1 ( 8 pt )

Travellers' & Singles' International Networks

for Travel, e-pals or pen-pals
for Travel Dating, Travel Mating, Adults

cccform.html

3   /   371 Morphett Road, Oaklands Park, Adelaide, SA 5046, SOUTH AUSTRALIA

Country City Contacts is designed to allow Travellers / Members in Countries / Cities / Regions & / or Oceanics, to be able to make contact with others in a similar position, World - Wide. The Membership / Registration Fee is now compulsory, but the Service is still on a Self - Help basis & is rendered in Good Faith.

As such, our Contacts Organisation is still significantly on a Donation basis ; any Financial Assistance that is offered by individual Members / Registrants & / or Body Corporates, to contribute to a reasonable share of all operating costs including Web Site & Data Bases Annual Charges, Designing, & Development ; professional time, advertising, mail handling, printing &stationery, photocopying, postage, etc., will be very much appreciated ; in addition to the AUD $ 35 ( Australian Dollars ) Membership / Registration fee, Page 4 of 4, also to be attached.

When your personal details is given to others, only your first name, initial, phone number ( or nearest Town / Suburb Locality Post Office Address ), & some particulars are issued. This allows initial contact to be made and if you feel that you would like further contact, it is then up to you to provide the caller or addressee with further details. For those who have no phone or prefer not to use it, contact will always be made by conventional post ( or e-mail ) using given name, initial, & C/o nearest Town / Suburb Locality Post Office ( or your Street Address, if you so desire ).

Please edit & post ONLINE
OR
download, print, fill - in, & post OFF - LINE ;

WHEN SENDING ANY DETAILS OR ENQUIRIES BY CONVENTIONAL MAIL, PLEASE ALWAYS INCLUDE A STAMPED SELF ADDRESSED ENVELOPE ( S.S.A.E. ) WHENEVER REQUIRED


STRICTLY PRIVATE & CONFIDENTIAL INFORMATION

Please fill in as much of your personal details below, as you feel comfortable with, for your CCC Membership / Application Form Pages 1 - 3 below ( Registration fee of AUD $ 35 ( Australian Dollars ) Page 4, also to be attached )
Please edit & post ONLINE
OR
download, print, fill - in & post OFF - LINE ;
All Confirmation(s) copies ;
ON - LINE, post by e - mail to
contacts@travellersoz.com.au
OR
OFF - LINE, post by conventional mail to C/o Registered Company Office, 3 / 371 Morphett Road, Oaklands Park, ADELAIDE, SA 5046, AUSTRALIA.

However, the successes of your compatible Match(es) depend on supplying as much Personal Information as possible.
Remove at any time by contacting Country City Contacts indicating that you no longer require the service, or have changed your address or destination.
All cancellations are subject to a non - Refund, for Administration and Handling costs. Please attach a non - returnable, dated & signed, recent passport size photo(s), if available or desired, also.

First / Given Name : Initial : Last / Surname :

Apartment / Suite / Street Address :

Country / Region / Oceanic : Other Specifics :
State / Province : Post / Zip Code :
Internet Country / Code : Other Specifics :
Ethnicity / Ancestory / Heritage : Main Language :

Page 2 of 4

E-mail Address(es) :
URL or Home Page(s) :
Purpose(s) of URL or Home Page(s) :

Toll Free Telephone / Fax ( if any ) : International Access Code : - Country Code : - Area Code :
- Telephone : Fax : Number : Best Time to Ring / Send : pm : or am :

in the event that you do not have a phone / fax, or wish not to use it : nearest Town / Suburb Locality Post Office Address : C/o

Post Office Street Address :

Post Office Other Specifics : Post Office, Post / Zip Code :

Education : Occupation :
Company : Purpose of Company :

Age Range in Years : Other Specifics :

Birth Date : / / Other Specifics :
Star / Animal Sign :

Sex : Female Male FSM (Female seeking Male) MSF (Male seeking Female) FSF (Female seeking Female)
MSM (Male seeking Male) Body Style / Type / Shape : Other Specifics :
Non Smoker : Smoker : Light / Social Drinker : Non Drinker :

Height Range : Other Specifics :

Weight Range : Other Specifics :

Property Status(es) : Marital Status / Relationship :
Children : Dependents :
Other Specifics / Marital & / or Property Status(es) ; Child(ren) & / or Dependent(s) :

Hair Colour : Eyes Colour :
Other Specifics Hair &/or Eyes :
Complexion / Other Characteristics :

Hobbies / Interests :

Sports / Activities :

Religion / Spirituality :

Likes / Dislikes :

Other : e.g. Travel Destination(s) / Holiday Itineries / Activitie, etc.:

 

 

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I wish my First Name & Phone No. / nearest Town / Suburb Locality Post Office Address ( or my Street Address ) & some personal particulars, to be given to Travellers / Members of the following details :-

Type of relationship(s) preferred : Other Specifics :

Preferred Country / Region(s) / Oceanic(s) : Other Specifics :
Internet Country / Code(s) : Other Specifics :

Sex : Female Male Age Range(s) : Other Specifics :
Star / Animal Sign(s) :
Non Smoker : Smoker : Light / Social Drinker : Non Drinker :
Body Style(s) / Type(s) / Shape(s) : Other Specifics :

Height Range(s) : Other Specifics :

Weight Range(s) : Other Specifics :

Preferred Marital Status(es) / Relationship(s) :
Children : Dependents :
Preferred Property Status(es) :
Other Specifics / Marital & / or Property Status(es) ; Child(ren) & / or Dependent(s) :

Preferred Hobbies / Interests :

Preferred Sports / Activities :

I UNDERSTAND THAT ONLY I WILL GIVE ADDITIONAL PERSONAL DETAILS TO ANY CALLERS / ADDRESSEES THAT I FEEL I WOULD LIKE TO CONTACT FURTHER

I CERTIFY THAT ALL INFORMATION THAT I HAVE SUPPLIED ON THIS APPLICATION FORM ARE TRUE & CORRECT, & HEREBY AUTHORISE USE , INCLUDING PHOTO(S) ( IF ANY ), IN ALL OF Country City Contacts SERVICE(S)

I AGREE THAT Country City Contacts cannot / will not, accept any responsibility of any meetings or contacts between Travellers / Members and / or other persons ; & reserve the right to refuse or withdraw membership of any persons, at Country City Contacts' sole discretion.

FULL NAME :
SIGNATURE : DATE : D : / M : / Y :
( Country City Contacts Applicant )
Computer Generated / CCC Applicant Membership / Registration Number :

PLEASE MAKE COPIES OF THIS APPLICATION FORM; FOR NOTICE BOARDS, & FURTHER COPIES TO FELLOW TRAVELLERS, FRIENDS & FAMILY.

your CCC Membership / Application Form :- Pages 1 , 2, & 3 of 4

 

 

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Page 4 of 4

To pay Country City Contacts your CCC Membership / Registration AUD $ 35 ( Australian dollars ) by BankSA Direct Credit(s) / Deposit(s), Credit Card, Bank Check ( Cheque ), or International Money Order, in that order of preference, please complete this last Page 4, of 4 ;
Please edit & post ONLINE
OR
download, print, fill - in & post OFF - LINE ;

All Confirmation(s) copies ; Post to your ( Debit ) Financial Institution for Payment. ; &
ON - LINE, post by e - mail to
contacts@travellersoz.com.au
OR
OFF - LINE, post by conventional mail to C/o BankSA, Head Office, 97 King William Street, ADELAIDE, SA 5000, AUSTRALIA.

Your Payment Method(s) :- Visa Card : Mastercard : Bankcard : American Express : Diners International :

Please charge AUD $ 35 to your Credit Card. Card Expiry Date : Day : / Month : / Year :
Your Credit Card Number : - / / /
Your Credit Card Verification Number / Electronic Commerce indicator values ( " eCommerce Indicator " ) : -
( the last three ( 3 ) Digits printed on the Signature Strip located on the back of your Credit Card )

or Your Other Payment Method(s) :- Bank Check ( Cheque ) or International Money Order or
Direct Credit(s) / Deposit(s) to Cowandilla Nominees Pty. Ltd.

         BRANCH    
  Name of Financial Institution  ACCOUNT TYPE  SWIFT CODE  BSB No.  Card / Account Number  
  receiving [ Credit ] Financial Institution           
Please CREDIT AUD   $   35  to   :- Bank of South Australia  CHECK (CHEQUE)  SBSAAU5A  105 - 000  0931966740 CR
OR Australian & New Zealand Bank ( A . N . Z . ) VISA CARD     4509 4952 3091 9177 CR

Full Address : Bank SA, Head Office, 97 King William Street, Adelaide, SA 5000, AUSTRALIA, OR
VISA CARD , Card Services, Australian & New Zealand Banking Group Limited ( A . N . Z . ), 13 Grenfell Street, Adelaide, SA 5000, AUSTRALIA.

Pay your DEBIT AUD $ 35 from : DR
( your paying [ Debit ] Financial Institution )

Full Name & Address of your paying ( Debit ) Financial Institution : Expiry DATE : D : / M : / Y :

FULL NAME :
SIGNATURE : DATE : D : / M : / Y :
( Credit Card / Account Holder only )

if Credit Card / Account Holder is different from Country City Contacts Membership / Registration Form, Applicant , above :
Full Address :
E-mail Address(es) :

Toll Free Telephone / Fax ( if any ) : International Access Code : - Country Code : - Area Code :

- Telephone : Fax : Number : Best Time to Ring / Send : pm : or am :

your CCC Membership / Registration & Payment(s) Authority AUD $ 35 :- Page 4 of 4


Hold down 'shift' while clicking this link to
Download text version of CCC Application form
Best viewed and edited in notepad with word wrap on.


PLEASE MAKE COPIES OF THESE POSTERS FOR NOTICE BOARDS, SO THAT YOU CAN ALSO GIVE COPIES TO FELLOW TRAVELLERS, FRIENDS & FAMILY
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Enquiries Jeff M. Weeks ; Copyright 1995 - 2000 COWANDILLA NOMINEES Pty Ltd A.B.N. 64 008081838
Web address;
http://www.travellersoz.com.au   Email address; contacts@travellersoz.com.au