ME/CFS Australia (SA) Inc
PO Box 28, Hindmarsh,
South Australia 5007


 
MEMBERSHIP APPLICATION FORM
 
 

Full Name:

( Mr / Mrs / Ms / Miss / Dr ) _____________________________________________________

 
 
Postal Address: ___________________________________________________________________

 
 
Suburb: ________________________________________   Postcode: ______________________

 
 
Phone: (H) _________________    (W) _________________
    (M) ______________________
 
 
Email: ___________________________
_________________________________________________
 
 
Date of Birth: ______ / ______ / ______

 
 
 
Which Best Describes You?
 
I suffer from:
 
Check box ME/CFS            Check box FM            Check box MCS            Check box Other ____________________________________

Or, I am a:
 
Check box Carer             Check box Relative             Check box Friend             Check box Health Professional / Scientist
 
 
 
Annual Subscription Rates – What Can You Afford?
(Rates are due on 1 July each year)

 
We think everyone affected by ME/CFS should be able to join our society – and not be prevented due to cost. So, please donate what you can afford, even if it's only $5*. It costs the society about $80 per year, per member, to operate. We used to ask $38 for an adult and $25 for concession. If you can donate more to help subsidise those less well off, we would all really appreciate it.
 
For my membership I wish to contribute: $ _________________
 
(*$5 of your contribution will be your official membership fee [GST inc.],
while additional contributions will be classified as donations. Donations
of $2 or more are tax deductable and receipts will be posted if required.)
 
Payable to "ME/CFS Australia (SA) Inc."

Send to: ME/CFS Society,
         GPO Box 28,
         Hindmarsh SA 5007
(please don't send cash in the mail)
 
 
 
Credit Card Payment
 
 
Name on Card: ___________________________________
 
 
VISA / MasterCard / Bankcard   EXP _____ / _____
 
 
Check boxCheck boxCheck boxCheck box  Check boxCheck boxCheck boxCheck box  Check boxCheck boxCheck boxCheck box  Check boxCheck boxCheck boxCheck box
 
 
Signature: ____________________________________

 
 
 
Miscellaneous
 
I agree to uphold and abide by the constitution of the ME/CFS Australia (SA) Inc. The constitution can be found on our website at http://sacfs.asn.au/society/member/index.htm.


Signed: _________________________________________   Dated: ______ / ______ / ______

 
Check box I would like to receive society notices (email bulletins with ME/CFS news, updates and reminders, etc) via email.
   
Check box I would like to receive society notices (seminar reminders and special notice of media events, etc) via SMS.
   
Check box I (or a friend or relative) would like to volunteer some time, service or business sponsorship to assist the society.
 
 
 
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Office Use Only

 
Date received: ______ / ______ / ______     Membership No:  _______________________
 
Entered in database:   ________________     Receipt No:     _______________________
 
Membership pack sent:  ________________     Volunteer name: _______________________

 
 
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