The Burgher Association
No.8, Pelawatte Roada Road, Nugegoda.
Tel: 4737796. e-mail:info@theburgherassociation.com
Website: www.theburgherassociation.com

MEMBERSHIP RENEWAL FORM






Year:
Date: ___________
Name/s: 1) ___________________________ Membership No/s: 1) _______________
2) ___________________________ 2) _______________
Date of Birth: 1) __________________
2) __________________

Change of Address/Telephone No. (If any): _________________________________________________________________

E-Mail address: ___________________________________________


OFFICE USE ONLY


Paid Rs. ________________ /= Cash/Cheque No: ___________________ Date: ____________
Bank/Branch: ________________________________________________
  Official Receipt No: ________________
_______________________________________________
Secretary's Signature/Official
__________________
Treasurer's Signature
Please note children having reached the age of 18 years should apply for new memberships.
Membership Fee: Family Membership Rs. 1,000/=. Individual membership Rs.500/= Overseas membership US$20
____________________
Member's Signature/Date