BEACON TV - operated by the

Nelson Media Access Trust Inc

Box 2108 Stoke Nelson New Zealand

Ph 03 544 7929

Email btv27@beacon27.org.nz

Website www.beacon27.org.nz

Ph one of our Trustees

Phone 544 7929

MEMBERSHIP APPLICATION FORM

I / We

Name …………………………………………………………………

Address …………………………………………………………………

…………………………………………………………………

…..……………………………………………………………..

Apply to become a Member of the Nelson Media Access Trust and in

doing so agree to make an Annual Donation to the Trust to maintain

my membership and to accept the conditions of membership as set

out in the Trust Deed.

Telephone ……………………….Fax ……………………...

Email: …………………………………………………………

Signed: ……………………………………

Date: ………………………………………