Royal Victorian Association of Honorary Justices

All Fields must be completed for a valid application to be processed. Enter N/A where a field is not applicable
Personal Details	Personal details listed below are for association use only and will not be released other than as required by law

TITLE
Last Name:
Given Names:
Occupation:
Home Address:
Town/Suburb:
Post Code:
Phone:<
Fax:
Mobile:
Email:
Business Suburb
Business Postcode
Business Phone:
Date of Birth:	DD: MM: YYYY:
Gender:	Male Female
JP Number:
BJ Number:
Public Details		Advise availability and preferred numbers for contact during the time frames indicated where you can be contacted by people needing your services
Availability	Any Time Business Hours After Hours
After Hours
Business Hours
BJ Primary Contact
Payment Details		On submission, your card will be debited in the amount of $67.90 ($45.90 membership plus $22.00 joining fee) GST included. Your membership certificate and email address will be mailed to your home address on acceptance by the board
Credit Card Type:	Visa MasterCard
Credit Card Number:	- - -
Expiration Date:	MM: YY:

ROYAL VICTORIAN