Australian Huntington's Disease Association (Qld)
Application for Membership Any adult interested in furthering the objectives of the Association is eligible for membership.
Title............... Name..........................................................................
Address.............................................................................................
......................................................................Postcode......................
Telephone ............................................Fax .....................................
Annual Fee for single membership is $13.20, or a special family subscription of $19.80 per year is available if more than one adult family member, living at the same address, wishes to join. Please nominate names of other adult members to be included.
(1).................................................... (2).................................................... (3).................................................... (4)....................................................
Could you please tick the appropriate box(es) below:
[ ] I hereby apply for single membership, and my annual fee of $13.20 is enclosed. (Price) includes GST.
[ ] I hereby apply for family membership and my annual fee of $19.80 is enclosed. (Price includes GST)
[ ] I am unable to pay the membership fee at present, but wish to receive newsletters.
[ ] Please delete my name from the membership list.
[ ] I am a professional working with HD families and would like to receive newsletters.
Profession...............................................Workplace.....................................
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