CIPSA Student Application by HC120831024421

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									                                                  CIPSA STUDENT MEMBERSHIP
                                                                        TAX INVOICE/ RECEIPT
Please update the following details and return to CIPSA with payment:
Preferred Contact (Please Select):                                Home                   Work

  FULL NAME
  COMPANY NAME
  ROLE TITLE
  EMAIL ADDRESS                                 Work:

                                                Home:

  CONTACT PHONE                                 Direct line:
  NUMBER
  (Incl. Area Code)                             Work Mob:

                                                Home:

                                                Mob:

  ADDRESS                                       Work:


                                                Home:



Please tick the appropriate rate below:
                       Australian Rates (Incl. GST)                                                      NZ & South Pacific Rates (GST Not applicable)
         Student Members*                                      P/T         AUD $210.00                 Student Members*                                        P/T          AUD         $186.00
         Student Members*                                      F/T         AUD $55.00                  Student Members*                                        F/T          AUD          $45.00
                                  st
NB: *Fees effective 1 November 2011 and subject to change at any time.

     PAYING BY CHEQUE (enclosed)                                                     PAYING BY CREDIT CARD:

    Visa             MasterCard                     A 3% surcharge applies for all Amex & Diners payments                                  Amex                 Diners Club

Card No:                                                                                         Exp. Date:                       /
Name on card:

Signature: ______________________________________________                                                              Today’s Date:                       /            /

Please debit: AUD $                                      Add 3% Surcharge for Amex or Diners (if applicable) TOTAL - AUD$

     Please tick this box to sign up for Annual Direct Debit from your Credit Card
(Minimum 2 years). Your card details will be kept in a secured file and you will be notified before monies are debited. Debit date and fee will be in accordance with your renewal date each year
and current grade. You will be required to notify us in writing to cancel direct debit




                       THIS DOCUMENT IS A TAX INVOICE/RECEIPT WHEN PAYMENT IS MADE IN FULL
           CIPS Australia Pty Ltd, Level 8, 520 Collins St, Melbourne VIC 3000. ABN: 32 111 330 262 CIPSA 09/10
t. +61 3 9629 6000 / 1300 765 142 f. +61 3 9620 5488 / 1300 765 143 e. membership@cipsa.com.au w. www.cipsa.com.au

								
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