ALCOHOL, TOBACCO and other DRUG COUNCIL (Tas)

							            MEMBERSHIP APPLICATION 2011 -2012
Membership Categories (includes GST)
A. Full Membership (voting)
       Non-Government Organisation
                  o (core annual income under $500,000)                                   $55 
                  o (core annual income $500,000 - $2,000,000)                            $77 
                  o (core annual income above $2,000,000)                                 $110 
       Individual                                                                         $11 
(Full membership is open to non-government, not-for-profit organisations who provide prevention, treatment,
rehabilitation, health promotion, education or other support services to Tasmanians affected by substance abuse
or that represent the interests of Tasmanian consumers of services related to the impact of substance misuse, or
the carers or family members of such consumers, and individuals committed to and able to contribute to the
purpose and objects of the ATDC.)

B. Associate Membership (non-voting)                                                      $55    
(Associate membership is open to nominated representatives of State and Commonwealth agencies or other
not-for-profit groups who have an interest in the provision of alcohol, tobacco and other drug services.)

Member Details
Organisation: _____________________________________________
Contact Name: _____________________________________________
Address: _________________________________________________
                  _____________________________________________
Postal Address: ____________________________________________
                  _____________________________________________
Email: ______________________ Phone: ______________________
Mobile:______________________ Fax: ________________________
Please include a copy of your Certificate of Incorporation along with a brief description of the
services your organisation provides to people affected by substance abuse. A copy of your
current Strategic Plan and your last Annual Report would also be appreciated. For Individual
Membership please provide some background of your interest in alcohol, tobacco and other
drugs and how you consider you are able to contribute to the objects of ATDC Tas.

The original of this form should be retained as your Tax Invoice once payment is made.

           A copy of this form should be sent with your payment to ATDC (Tas) Inc
                     Suite 6, 81 Salamanca Place, Battery Point Tas 7004

Details for Electronic Funds Transfer: BSB: 633 000 Account No.:124 559 683
Account Name: The Alcohol, Tobacco and Other Drugs Council (Tas) Inc.
           Your membership application will be considered at the next ATDC Board Meeting

                      Telephone: (03) 6224 7780     Fax: (03) 6224 7800
                                Email: reception@atdc.org.au
                                     ABN: 91 912 070 942