Page 1 of 2 COUNTRY CITY CONTACTS Travellers’ & Singles’ International Network for Travel, e-pals or pen-pals 3 / 371 Morphett Road,Oaklands Park, Adelaide, SA 5046, SOUTH AUSTRALIA meaningful membership - sincere service for lonely or alone Travellers / Members Country City Contacts is designed to allow lonely or alone Travellers / Members in City & Country Regions to be able to make contact with others in a similar position. The Membership / Registration, is on a voluntary & self help basis; The service is rendered in good faith. As our Contacts Organisation is run on a self-help and donation basis; any financial assistance that is offered to contribute to a reasonable share of all operating costs including Web site annual charges, 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, also to be attached. When your name 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 using given name, initial, & C/o nearest Town / Suburb Locality Post Office (or your Street Address, if you so desire). Please Download both; this Country City Contacts Application Form; and your Payment Authority / Transaction Coupon / Slip, at bottom of Page 2 below; for AUD $35 (Australian Dollars), International Money Order, Bank Check (Cheque), or Credit Card, & Complete, fill-in & post Confirmation(s); by conventional mail &/or Edit & e-mail to contacts@travellersoz.com.au WHEN SENDING ANY DETAILS OR ENQUIRIES, PLEASE ALWAYS INCLUDE A STAMPED SELF ADDRESSED ENVELOPE (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 Membership / Registration fee of AUD $35 (Australian Dollars), also to be attached; Remove at any time by contacting Country City Contacts indicating that you no longer require the service, or have changed your address or destination. Please attach a non-returnable, dated & signed,recent passport size photo(s), if available or desired, also. Given Name:...............................................Initial:.......... Surname:.................................................................... Street Address:............................................................. ............................................................. Country / Region:........................................................... ........................................................... Post / Zip Code:....................................... Telephone: (..............)- ................... - ................... (International access / area code) Best Time to Ring:....................................... in the event that you do not have a phone or wish not to use it: C/o nearest Town/Suburb Locality Post Office Address:C/o............................................................... Post / Zip Code:........................................ Education:.................................................................. Occupation:................................................................. Age in Years:..................... Birth Date:.............../.............../................. Birth Sign:................................................................. Sex: Male / Female ; Height:...........cms Weight:............Kg Marital Status:*...................... Children:................... Dependents:................ Colour Hair:...................... Colour Eyes:........................ Complexion:...................... Other Characteristics..................................... Hobbies / Interests:........................................................ ........................................................ ........................................................ Sports / Activities:........................................................ ........................................................ ........................................................ Smoker / Non Smoker ; Social Drinker / Non Drinker Religion:................................................................... ............................................. Likes / Dislikes:........................................................... ........................................................... ........................................................... Other: e.g. Travel / Holiday Activities..................................... ...................................................................... ...................................................................... Page 2 of 2 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: Travel / Holiday Activities / e-pals or pen-pals Correspondence / Friendship /De facto / Marriage Preferred Country / Region(s) Australasia / Europe/ North Americas / Asia / Pacific / South Africas / South Americas / North Africas / Other Specifics............................................................. ............................................................. Age Range................................ Sex: Male / Female Height:...............cms Weight:................Kg Marital Status:*.................................. Interests / Sports:......................................................... ......................................................... ......................................................... Smoker / Non Smoker ; Social Drinker / Non Drinker Children................................ Dependents................................. * Please specify for both particulars: NM = Never Married, DI = Divorced, WI = Widowed, SE = Separated, DF = De facto 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 THATI 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:...../....../...... (Country City Contacts Applicant) PLEASE MAKE COPIES OF THIS APPLICATION FORM ;FOR NOTICE BOARDS, & FURTHER COPIES TO FELLOW TRAVELLERS, FRIENDS &FAMILY.   cut/tear=======================================================================================================================cut/tear To pay Country City Contacts AUD $35, by International Money Order, Bank Check (Cheque), or Credit Card, Please Download & Complete ; fill-in & lodge with your (Debit) Financial Institution for Payment. Post Confirmation(s) copies to Country City Contacts'(Credit) Financial Institution for Deposit(s); to BankSA, Head Office,97 King William Street, Adelaide, SA 5000, AUSTRALIA ; &/or Edit & e-mail to contacts@travellersoz.com.au                                                                                                                               BRANCH Name of Financial Institution   ACCOUNT TYPE   SWIFT CODE  BSB No.   Card / Account Number Please CREDIT AUD $35 to :- Bank of South Australia   CHECK(CHEQUE)  SBSAAU5A  105-000  0931966740 CR         OR Bank of South Australia   BANK CARD                5610 5452 0134 8955 CR Full Address : Head Office, 97 King William Street, Adelaide, SA 5000, AUSTRALIA, OR BANK CARD , Card Services, Box 1518 G.P.O., Adelaide,SA 5001, AUSTRALIA. with DEBIT AUD $35 from :-..........................................................................................................................................DR Full Address of (Debit) Financial Institution: ......................................................................... Expiry Date:...../...../..... FULL NAME:................................................................. SIGNATURE..................................DATE:...../...../.../... if Credit Card Holder is different from Country City Contacts Membership / Registration Form, Applicant , above : Full Address:................................................................ ............................................................... ............................................................... Telephone: (..................)-..................... - .................... (International access / area code) Best Time to Ring:...................................