Application for Associate Membership
  1. APPLICATION FOR ASSOCIATE MEMBERSHIP 2012-13
  2. Individuals with lived experience of mental illness (consumers) are eligible for free Primary Membership. If you identify as a consumer DO NOT complete this form. Instead, fill in the Primary Membership Application.
  3. CONTACT DETAILS
  4. Your name and at least one contact address/email is required
  5. Organisation/group
  6. (if applicable)
  7. Type of organisation/group
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  8. (if applicable)
  9. Contact person(*)
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  10. Please specify
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  11. First Name(*)
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  12. Surname(*)
    Please let us know your name.
  13. Address(*)
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  14. Postal Address (if different)
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  15. Email
    Please let us know your email address.
  16. Home Phone
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  17. (if individual)
  18. Office Phone
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  19. Mobile Phone
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  20. Other Contact
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  21. Website
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  22. INCLUSION/ENTITLEMENTS
  23. - Quarterly Newsletters
  24. - Your logo, info and link on our website
  25. - Promotion of your events
  26. - Use of meeting space
  27. - Partnership and collaboration
  28. - Election to the Network’s Board
  29. STATUS(*)
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  30. COMMUNICATION PREFERENCES:
  31. Best way to contact me(*)





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  32. Do you want to receive Newsletters and other information?(*)



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  33. Please send information about AGM and other major events to:(*)



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  34. ANNUAL CONTRIBUTIONS
  35. In order to support the Network’s core programs and enable beneficial relationships with like-minded organisations and groups there is a small annual contribution per organisation/group or individual. Individuals who hold a concession card are not required to pay the contribution. Organisations/groups and individuals who feel they are unable to pay their contribution may be eligible may request a contribution waiver or reduction.
  36. Contribution(*)




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  37. (please provide a copy of your current concession card)
  38. PAYMENT METHODS
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  39. Made out to: ACT Mental Health Consumer Network
  40. Account Name: ACT Mental Health Consumer Network
  41. Account Number: 10168614
  42. BSB: 062-919