Please complete the form below and send it (with your payment) to :
ASOR Inc. (Melbourne Chapter) P.O. Box 1048HGPO Melbourne 3001
If you plan to pay by credit card, please also fill-in the
Credit Card Slip Form
$70* per corporate member Free for student members
*A $5 discount applies if you pay before March 2005.
Grade of Membership Applied for Member Associate Student
First name
Last name
Other name
Unit/Department
Organization
Street
City
State, Postal Code, Country
Telephone (H)
Telephone (W)
Fax
E-mail:
If this is not your first application for membership, give details (on a separate sheet if necessary) of current status of previous application and/or membership, and include name of Chapter
Details of relevant experience
Dates
Employer & Position
Relevant Experience
Details of Qualifications
Year
Institution
Qualification Obtained
Details of Current Studies
Course of Study
Details of two ASOR members who agreed to nominate you
Name
Contact Information
I declare that the information given above is true and correct in all particulars. If admitted to ASOR, I undertake to be bound by the Society's Constitution and By Laws. In payment of my first annual subscription I enclose the sum of $
Signature
Date