Application for Student/Associate Membership
Please complete the following form and return it to:- the address at the foot of the page.
Please indicate which membership you require:-
STUDENT / ASSOCIATE (Please circle one)
Date:________________
PERSONAL DETAILS
Surname ………………………………………. Given Names ………………………………………………..
Home / Postal Address ………………………………………………………………………………………………………………………………
…………………………………………………………..………………………………………………………………….
City/ Town.…………………………………… State…………………..… Post Code ……..………….
Telephone ………………………………………………………………….
Email address …………………………………………………………………………………………….
Applicant’s Signature………………………………….. Witness………………………………………
Date of Birth ………………………………………….. Witness Address………………...........
…………………………………………………
Note: Payment of $25 each year is required to maintain membership.
Credit Card Payment - __Visa __Master Card Amount $____________
Card Holders Name ______________________________________________
Credit Card Number: __/__/__/__ __/__/__/__ __/__/__/__ __/__/__/__
Expiry Date ____/____ CCV # ___/___/___ (last 3 digits on back of card)
Signature ______________________________________ Date__/__ __/__ 201__
OFFICE USE ONLY
Payment Details:-
Method - Cheque No. Money Order No : Cash.
Bank/internet Deposit: Bendigo Bank. BSB:633 000 Acc No:125 168 633. Reference: your name
PLEASE MAKE ALL CHEQUES AND MONEY ORDERS PAYABLE TO ‘I.C.A.N.T Inc’
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