Receive a personal message from the Lord Mayor

Please complete the following form to receive your own personal email message from the Lord Mayor Graham Quirk. If you would like more friends to also receive a personal email message from the Lord Mayor then complete the second referral form that loads once you have submited your details. Each time you hit submit, the form will be refreshed so you can refer as many friends as you wish.

To receive a personal message from Lord Mayor Graham Quirk please complete this form in full
Please complete the following form with information we require to send you a personal message from the Lord Mayor.
Your First Name:	*
Your Surname:	*
Your Email Address:	*
You will automatically receive an online Birthday Card and Christmas Card.
If you would like to receive another type of card, please provide further information here. :	Please leave blank if not applicable
Would you prefer a printed card in the post AND the online card via email?:	No Yes
*Please note: Printed cards will only be sent for 50th and 60th Wedding Anniversaries and 100th Birthdays. All requests must be received at least 2 weeks prior to date required*
Birthday (Date that you would like to receive the card - DD/MM/YYYY):	*
Your Postal Address 1:	*
Your Postal Address 2:
Your Suburb:	*
Your State:	*
Your Postcode:	*
	Type the characters you see in the picture below. Letters are not case sensitive