Membership Management Details Form

Enter the details of your membership, then submit this form. The details submitted will be used to setup your membership management. We will contact you once we have set up a draft of your membership form to confirm details.
NOTE: If you are unable to complete some of the details on the form we will collect them from you when we call.

Company Details/Contact Person

Company Name*

Company Business Number

Company Address*
(for invoices)

City*

State

Zip/Postcode

Contact Person *

Position

Phone* - Fax

Email*

Company Website

Event Details

Membership Name*

Date Start*

Date End*

Short Summary*
(approx 3 lines)

Description / Details

Registrations

Max number member

NOTE: ALL Prices to include TAX if applicable

Membership Costs

Types	Cost (AUD$)	Earlybird (AUD$)

Registration Cutoff(Last Day)*

Early Bird Cutoff
(Last Day)

Payment Methods / Options

Deposits Permitted

Yes No Amount (AUD$) Amount (%)

Credit Card Pmts

Yes No

Cheque Pmts

Yes No (If Yes then supply details below)

Cheque made to name:
Cheque send to address:

Direct Deposit Pmts

Yes No

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