LICA MEMBERSHIP FORM

 

MEMBERSHIP NUMBER:

 

 

REFERRED BY:

 

 

 

 

 

          NEW MEMBER

        RENEWAL

       CHANGE OF DETAILS

 

 

LIQUOR LICENSE NUMBER:

 

 

NAME:

 

 

VENUE/ORGANISATION:

 

 

ADDRESS:

 

 

CITY:

STATE:

P/CODE:

 

 

EMAIL:

MOBILE:

 

 

WORK PHONE:

FAX:

 

 

 

I wish to apply for membership with the Gold Coast Liquor Industry Consultative Association Inc. (LICA)

 

I agree with the principles set out in the LICA Accord document and will support this Accord by promoting best practice in our Industry.

 

 

 

SIGNATURE:

 

 

NAME:

DATE:

 

 

 

PLEASE FAX COMPLETED FORMS TO (07) 5528 6773 OR EMAIL: info@lica.com.au