ME/CFS Australia (SA) Inc
GPO Box 383, Adelaide,
South Australia 5001

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
(Rates are due on 1 July each year)
 
         
Membership
 Check box $38 (incl. GST)   Single
Subscriptions
 Check box $25 (inc GST)   Single (concession)
(includes Journal)
   Please circle one:   DSP / Student / Unemployed /
Age Pension
  Check box $45 (inc GST)   Family
  Check box $38 (inc GST)   Family (concession)
         
ADD
 Check box $10   Overseas members
         
 
Plus Donation   $ _________________   Your donation will greatly assist the society’s work.
 
All donations of $2 or more are tax-deductible and a receipt will be posted to you.
 
Total enclosed   $ _________________   Payable to “ME/CFS Australia (SA) Inc.”

Send to: ME/CFS Society,
         GPO Box 383,
         Adelaide, SA 5001
(please don’t send cash in the mail)
   
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.
   
 
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: ____________________________________
 
 
 
 
 
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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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