ASOR (Melbourne Chapter) Membership Application Form
Payment by Credit Card

Annual Membership Fee (January 1 - December 31, 2005)

$70* per corporate member
(Free to students!)

* A $5 discount applies if payment is made before March 2005

Applicant     

Title
Last name
First name
Middle initial

Telephone (H)
Telephone (W)
Fax
E-Mail:

Credit Card Details

Please debit the amount of $ to my Credit Card account for payment of the annual membership fee. The details of my Credit Card are as follows:

 
Type
Credit Card Number
 
Expiry Date
Name of Card Holder
 
 
* AMEX batch code number
 

______________________________________
Signature of Card Holder

_____________________________
Date(dd/mm/yy)

Attatch this form to the Application Form and send to

ASOR In (Melbourne Chapter)
P.O. Box 1048H
GPO Melbourne 3001