Autism Association of Western Australia (Inc) Locked Bag 9 West Perth WA 6872 Fax 9489 8999 ABN 54 354 917 843

APPLICATION FOR MEMBERSHIP / TAX INVOICE

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……………….….……

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Please debit my Bankcard / Mastercard / Visa $………………. Expiry Date:………...…….……….…

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Name on Card……………………………………… Signature …………………….………………….

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Membership Fees for each calender year ( 1^st January to 31^st December ) $25 inc GST per family (up to 2 members over the age of 18 years)

Membership Fees for Organisations / Professionals each calender year ( 1^st January to 31^st December ) $35 inc GST

**PLEASE KEEP A COPY OF THIS APPLICATION FORM AND USE AS A TAX INVOICES IF REQUIRED