Membership Application Request

Dystrophic Epidermolysis Bullosa Research Association of Australia, Queensland

Membership Year 2006/2007

To become a member fill in the following request form, submit it and a representative of our organisation will process your request personally. Upon payment a written acknowledgment and receipt of your membership will be promptly forwarded to you. Alternatively you may simply wish to print the form and mail it to us, regardless, we want your support and we're here to make it as simple as possible for you.

Membership Type

New Membership      Re-New Membership

Membership Details

Name
 * This field is required
E-Mail
 * This field is required
Address
Telephone
* This field is required
Mobile/BH
Facsimile

Membership Category

Single
Family
Affiliate
This membership fee, which includes the G.S.T., entitles you to attend meetings and vote, & to receive meeting minutes and newsletters.
AUD $5.50 (For an adult over 18 who has EB)

AUD $8.25 (For parents or guardians of a child with EB - includes all siblings)

AUD $5.50 (For a person interested in the Association's aims, who is excluded from the above two categories.)
Fees include GST
Cheques/money order to be made payable to DEBRA-A Qld

Correspondence

Would you like us to display your membership details in the "Member listing"?
Would you like us to send you e-mail notification of the latest website "News and updates"?
Would you like us to send you newsletter and other correspondence by "regular mail"?

Yes  No
Yes  No
Yes  No

Comments and Suggestions

Payement Details

DEBRA-A Qld,
C/- P O Box 226
Pittsworth Qld, 4356
Australia, 4065. Tel: (061) 074 693 7247
Special note:
DO NOT enter any bank details in this form, if you have done so please remove them now. If you prefer to personally apply for membership please click this checkbox:

Confirm Totals

Membership Fee
AUD$
Pledge Donation
AUD$

Date Stamp Request

Enter today's date
* This field is required

  • Please check your name, email, telephone and date is entered.
  • Please check personal details and membership category
  • Please check amounts are correct and you have our payement details


    • Upon pressing SUBMIT this form will be routed through Diggy Internet services, a copy will be sent to you and also forwarded to DebRA Queensland.. Thank you for your co-operation.

    Agreement

    I agree that this request is subject to commitee review and all information provided is true and correct