Associate Membership Application 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, complete a Primary Membership Application. Contact details (Your name and at least on contact address/email is required) Organisation/group name (if applicable): Status Organisation/groupIndividual (eg. Carer) Type of organisation/group (if applicable): Contact Person Title MrMrsMsMissOther (please specify) First Name Surname Address Street Address Suburb State ---ACTNSWNTQLDSATASVICWA Postcode Postal address (if different) Street Address or PO Box Suburb State ---ACTNSWNTQLDSATASVICWA Postcode Email Address Home Phone (if individual) Work Phone Mobile Phone Other contact Website Communication preferences What is the best way for us to contact you? EmailHome/Work PhoneMobile PhoneSMSPost Do you want to receive newsletters and other information? Yes by emailYes by post How should we send information about AGM's and other major events? Home/Work addressPostal addressEmail Annual Contributions In order to support the Network's core programs and enable beneficial relationships with like-minded organisation 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 to request a contribution waiver or reduction. Organisation/Group Annual Funding Level and Contribution Rate < $100,00 ($60.00)> $100,00 ($120.00) Individual Concession (Free) Please upload a copy of your current concession card here (jpeg, png, pdf and docx file types acceptable) Non-concession ($25.00) Payment methods Cheque Please make your cheque out to ACT Mental Health Consumer Network EFT Account Name: ACT Mental Health Consumer Network Account Number: 10168614 BSB: 062-919 Than you for taking the time to complete and submit this information.