Ménière’s Support Group of Victoria Inc

Membership Application Form

Please complete this membership application form. You can type in the information, then print it out. Or you can print a blank form, then fill it in by hand. Either way please remember to sign the form! Post the completed form together with your cheque, money order or credit card authorisation in Australian dollars (AUD$). If you prefer, contact us and we can post you a printed application form.

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Contact Information (required)
Title	(Mr/Mrs/Ms/Miss/Dr)
First name
Surname	Date of Birth
Street address
Postal address
City & state
Postcode/Zip
Country
Phone (BH)
Phone (AH)
Email

Permission for inclusion on the MSGV member contact list (optional)
I give permission for my: name address phone number(s) email address to be included in the confidential MSGV membership contact list.
Occupation (optional)

Payment due (required)
Initial joining fee (includes subscription for first year)		Pension/Health Care Card holder membership: AUD $42.50 Full membership: AUD $85.00 Health professional: AUD $95.00
Donation AUD$		The MSGV is a non-profit organisation and donations are gratefully received. Donations over $2.00 are an allowable tax deduction in Australia.
Total payment
Health Care Card No		or Pension No

Payment method (required)
I want to pay membership fees to the Ménière’s Support Group of Victoria Inc via:
Cheque Please make cheques payable to Ménière’s Support Group of Victoria Inc
Enclosed is my cheque / money order for AUD$:
Credit card: Please debit AUD$ to my:
Visa Mastercard
Cardholder's name:
Card number:
Expiry date:
Signature:

Signature (required)
I wish to become a member of the Ménière’s Support Group of Victoria Inc:
Signature:		Date: / /
Post your completed form to: Membership Secretary Ménière’s Support Group of Victoria Inc 4/18-28 Skye Rd Frankston Victoria 3199 Australia		Print this form Back to top
MSGV respects the privacy of your personal information. Personal information is collected on this form for the purpose of maintaining the membership database and provision of services.
Please take the time to fill in our online member survey. The information you give us will help us improve our services to members.

Ménière’s Support Group of Victoria Inc

Membership Application Form

Contact Information (required)

Permission for inclusion on the MSGV member contact list (optional)

Occupation (optional)

Payment due (required)

Payment method (required)

Signature (required)