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Become
a Member of the Epilepsy Centre SA & NT Today
Membership
application
Title Dr/ Mr / Mrs / Ms
First
Name................................................................
Surname....................................................................
Organisation............................................................
Address....................................................................
Suburb.............................................
State...............
Postcode..................................................................
Phone
(daytime)......................................................
Fax.............................................................................
Email..........................................................................
Annual Membership Fee
(Renewable 1st July each year)
 |
Concession |
$11.00 |
|
Family |
$22.00 |
|
Single |
$22.00 |
|
Support
Organisation |
$22.00 |
|
Other
Organisation |
$22.00 |
(GST
included)
Membership
fee enclosed
|
|
$...................
|
I
wish to make a Donation of
|
|
$................... |
Donations
over $2.00 are tax deductible
|
|
|
| Total
enclosed |
|
$................... |
Please
find enclosed my cheque/money order or
Debit
$................... from my
|
Bankcard |
|
Visa |
|
AMEX
|
|
Mastercard |
|
Diners |
Card
No................/................/................/................
Name
on card..........................................................
Expiry
Date................/................
Signature.................................................................
Please
mail to: Epilepsy Centre, P O Box 12, Woodville
SA 5011
Or
Fax (08) 8445 6387
Please
Note: The Epilepsy Centre is unable to accept credit card
payments by email.
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