Membership Application Form

    All prospective members of VITACHOICE LTD are required to complete this registration form. Indicate any changes; Membership runs from 1st July - 30th June.

    Driven purely by charity, not by profit, we solemnly vow to apply scientific reason to overcome suffering and to diligently forge a joyous body and mind. Accordingly, I , swear to join this Charity and keep all its rules and regulations with a will.

    PART A: MEMBER CONTACT INFORMATION

    Title:

    Name:

    Date of Birth:

    Address 1:

    Address 2:

    Town/City:

    Telephone:

    Country:

    Mobile:

    Job Title:

    Email:

    Please note that the phone number and email will be listed in the VITACHOICE LTD Register of Members.

    PART B: MEMBERSHIP TYPE AND PAYMENT DETAILS

    Member Type

    Description

    Annual Fees — Please Tick

    Full

    Full Membership

    AUD 1,000

    Student/Retired

    Full-time students and Retired Members

    AUD 500

    Payment Method

    PART C: MEMBER INFORMATION AND PERMISSION TO USE PHOTOGRAPHIC IMAGES

    Would you like to receive VITACHOICE LTD membership information?

    Photographs of VITACHOICE LTD members may be used in various communications including the newsletter and website. Group photographs taken at VITACHOICE LTD events may be used without identifying individual members. For individual photographs, please indicate your permission for use:

    Online Payment

    Check

    Bank Name: National Australia Bank

    Account: 289160637

    BSB: 084 034

    SWIFT/BIC: NATAAU3305A

    Account Holder: VITACHOICE LTD

    Bank Address: 71 Smith Street, Darwin, Northern Territory, 0800, Australia

    If you use check to pay, please send the check to below:

    110/12 Salonika St, Parap, NT 0820

    After signing the form, please email a copy to vitachoice.clg@gmail.com

    Applicant Signature:

    Signature of Proposer:

    Signature of Board Member:

    Submitting Date:

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