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Autism Association of Western Australia (Inc) Locked Bag 9 West Perth WA 6872 Fax 9489 8999 ABN 54 354 917 843 |
Please complete the following information to apply for
Membership.
PERSONAL DETAILS
Mr/Mrs/Miss/Ms
.. GivenName Surname Occupation
Spouse / Partner Details
Mr/Mrs/Miss/Ms . GivenName Surname Occupation
·
Details
of Family Member with Autism (If more
than one person please attach further information.)
Name
..
..
. Date of Birth.
.
../.
...
/
.. Gender
.
... ( M/F)
Diagnosis
....(Autism, Aspergers, PDD/NOS)
Relationship to
Member
... (son, daughter, niece, nephew etc))
Languages spoken at home (other
than English)
..
.
ORGANISATION /
PROFESSIONAL DETAILS (for
Organisational / Professional members only)
Name:
.
ABN If Applicable
... /
../
../
.. Contact Name
.
OTHER DETAILS
Address:
.
..
.Post
Code
E-Mail
.
..
Telephone: Home ..
...
.. Business
...
..
..
Mobile
.
.
___________________________________________________________________________________________
_ _ _
_ / _ _ _ _ / _ _ _ _ / _ _ _ _
Name on Card
Signature
.
.
___________________________________________________________________________________________
Membership
Fees for each calender year ( 1st January to 31st
December ) $25 inc GST per family (up
to 2 members over the age of 18 years)
Membership
Fees for Organisations / Professionals each calender year ( 1st
January to 31st December ) $35 inc GST
**PLEASE KEEP A COPY OF THIS
APPLICATION FORM AND USE AS A TAX INVOICES IF REQUIRED