MEMBERSHIP APPLICATION FORM
2018/2019 Membership $10.00
Name/s:
Postal Address:
Phone Number: Mobile:
Email:
Date of Birth:
Membership: $10.00 per person $
Would you like to make a Donation to the Asbestosis & Mesothelioma Association of Australia Ltd?
Donation Amount: $
Please select one of the following payment methods:
Cheque
❑
Money Order
❑
Cash
❑
EFT
❑
Cheques and Money Orders made payable to Asbestosis & Mesothelioma Association of Australia Ltd
EFT Bank Details: Bank of Qld BSB: 124 063 Account: 22274522
I hereby apply for membership of the Asbestosis & Mesothelioma Association of Australia Ltd for the
financial year 2018/2019 and agree to be bound by the Terms of the Association’s Constitution and
understand I have full voting rights in accordance with the Association’s Constitution.
Applicant/s Signature:
Date:
Office Use Only Receipt Issued: Entered in Register:
Asbestosis & Mesothelioma Association of Australia Ltd PO Box 1178 Tweed Heads NSW 2485 Ph: 1800 017 758
or 0426 537 437 Website: www.asbestosassociation.com.au Email: info@asbestosisassociation.com.au ABN: 59 602
979 000
