Title: Mr Mrs Ms Miss Dr Prof

Name: Surname Given Names Preferred Name

Phone: Home Office Mobile

Email:

Date of Birth: (This indicates when you will be eligible for Fully Paid Up Membership)

Summary of Service:

Years, locations, jobs, etc

Spouse/Partner Name:

Membership Fee:

Annual membership fee is $5.00 for ordinary members and $2.50 for country members. Fees are requested to be paid in advance for four years. Payment may be made by EFT to BSB 064-011 Account 00902825. Please include your name in the payment reference and enter the reference below in this form.

Payment Reference: Membership Class: Ordinary ($20) Country ($10)