Individual Membership Application Form Template

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Individual Membership Application Form Template Powered By Docstoc
					Individual Membership Application Form
ABN 73 917 799 818
Inc. Assoc. No. A0039738V


 Yes, I would like to:              Join WIC               Join the WIC Mailing List
 Name:
 Position:
 Organisation/Company:
 Postal Address:
                                                                                                       Post Code:
 Email:
 Phone: (work hours)
 Mobile:

 Please tell us a little about yourself:
  Who do you work for?                                       Public Sector       Private Sector      Education       Other
  What brought you into this industry?                       Formal Training        Opportunity      Other__________________
  How long have you been in this industry?                   Less than 2 yrs       2 – 5 years      5 to 10 years       10+ years
  How long do you envision yourself to                       Less than 1 yrs       1 – 5 years      Rest of Career       Unsure
  remain in this industry?
  How would you describe your current                        Cadet       Operational      Middle Manager        Senior/Exec Manager
  role?
 If you are interested in participating in one of the WIC committees, please tick appropriate box:
    Membership               Events                 Champion Activities             Marketing & Communication                     Media & PR


 MEMBERSHIP CATEGORIES
    $50.00      Individual Membership (please note that a free membership is included if you purchase the entire
                 Hot Breakfast Series – visit WIC’s website for further details)
    FREE        Full-time Students/Mailing List
 More information on WIC membership can be found at: http://www.wic.org.au/membership.aspx

 PAYMENT METHODS
    Paypal (online at http://www.wic.org.au/membership.aspx)
    Credit Card (VISA/MASTER)            Card Holder Name:                                     Expiry Date:                 .
                                         Card Number:                                                                           .
    Cheque
    EFT      DETAILS – WIC, NATIONAL AUST BANK, BSB No: 082 962, Account No: 4873 45608 quoting your name
    Please record your payment receipt #

 Please complete this form & return to: emailWIC@gmail.com


 RECEIPT / INVOICE – This document will become your RECEIPT / INVOICE when completed & payment is made in full so please
 keep a copy for your records. As a non-profit organisation with turnover below the GST threshold, GST does not apply.

 PRIVACY DISCLAIMER – The collection of these details is primarily so that we can register you as a member of WIC. This
 information will be stored in the WIC database and may be used for future marketing of WIC’s Events. If you do not wish your details to
 be made available, please tick this box [ ]. If you do not tick the box, then WIC will consider that the individuals completing this form
 consent to their personal details being used in the manner indicated.


    Women in Information & Communication                                                           Contact: WIC Secretary
    GPO Box 2579                                                                                   Email: emailwic@gmail.com
    CANBERRA ACT 2601                                                                              Website: http://www.wic.org.au
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