Membership Application

Individual or family. Your information is confidential and used only to consider your application (see our privacy notice).

Application type

IndividualFamily

Membership sought

Title

Full name

Date of birth

Marital status

Date of marriage

Gender

FemaleMalePrefer not to say

Mobile

Address in Australia

Address in India

Optional

Home parish

Optional

Emergency contact

Someone we can contact in an emergency. This is kept private and seen only by authorised parish officers.

Full name

Relationship to you

e.g. Brother, Friend, Neighbour

Contact number

Secondary contact number

Optional

Are you a member of any other Jacobite church in Australia?

YesNo

Declaration

I/We hereby confirm that the details provided here are true and correct to the best of my/our knowledge and belief. I/We also proclaim my/our unflinching obedience and loyalty in the Faith, Tradition, Principles and Practices of the Jacobite Syrian Orthodox Church, and agree to abide by the constitution of St Basil Jacobite Syrian Orthodox Church Melbourne Incorporated.

Signed (type your full name)

Place

I/we affirm the declaration above.I/we consent to the parish handling this information per the privacy notice.

Membership Application

Individual or family. Your information is confidential and used only to consider your application (see our privacy notice).

Application type

IndividualFamily

Membership sought

Title

Full name

Date of birth

Marital status

Date of marriage

Gender

FemaleMalePrefer not to say

Mobile

Address in Australia

Address in India

Optional

Home parish

Optional

Emergency contact

Someone we can contact in an emergency. This is kept private and seen only by authorised parish officers.

Full name

Relationship to you

e.g. Brother, Friend, Neighbour

Contact number

Secondary contact number

Optional

Are you a member of any other Jacobite church in Australia?

YesNo

Declaration

Signed (type your full name)

Place

I/we affirm the declaration above.I/we consent to the parish handling this information per the privacy notice.