Ménière’s Support Group of NSW Inc.
Application For Membership
Dr./Mr./Mrs./Ms./Miss......................................................................................................
Postal Address....................................................................................................................
......................................................................................................Postcode.......................
Date Of Birth..........................................Telephone No..............................................
Occupation..........................................................................................................................
How Did You Hear
About The Support Group?..........................................................................................
(Please
Tick)
Are You Under A Doctor's Care?.................... 
YES NO
Do
You Suffer From Loss Of Hearing Vertigo Tinnitus
Would You Agree To Have Your Name And 'Phone No. Given To Other Persons In
Your
Area With Ménière's Disease?............. YES NO
|
Membership |
Joining Fee |
Annual Subs. |
Total |
|
Ordinary |
$25 |
$27.50 |
$52.50 |
|
Pensioners |
$25 |
$15 |
$40 |
|
Professionals |
$25 |
$40 |
$65 |
All fees include GST:
Cheque/ Money Order enclosed:-
Joining Fee $ .................................................
Subscription $ ................................................
Donation $ ........................................................
TOTAL $ ...........................................................
or Credit Card
Australia: Bankcard, MasterCard or Visa.
Overseas: MasterCard or Visa only
CREDIT CARD DETAILS: Bankcard MasterCard Visa
Number: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Name on Card (please print): ______________________________________
Payment Amount: $______
(Note: Postage will be added to overseas orders)
Expiry date: ___ / ___
This is a volunteer organisation. All donations $2 and over are tax deductible within Australia.
Please print out this form and return together with your Cheque or Money Order or Credit Card Details to:
Membership
Secretary
PO Box 2134 BOWRAL NSW 2576
For further information see the Contacts Page
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Click on this link to go to our home page: http://www.menieresnsw.org.au/