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MA Membership Application Form

Apply for Membership

MA membership has fabulous benefits, and puts you in touch with others living with Meniere's and other vestibular disorders around Australia and the world.

Contact Information

Title:
First Name:
Surname:
Date of Birth:
Street Address:
Postal Address: (Optional)
City/Suburb:
State:
Postcode:
Country:
Phone (BH):
Phone (AH):
Email:

Permission for inclusion on the MA member contact list (optional)

I give permission for my:
Name: Address: Phone Number(s): Email:
to be included in the confidential MA membership contact list.

Occupation: (Optional)

How did you hear about MA?:

Membership Category

Pension/Health Care Card holder: $85.00
 
Full membership: $105.00
 
Health professional: $125.00
 
Organisation membership: $155.00
 
Donation: $ MA is a non-profit organisation and donations are gratefully received. Donations over $2.00 are an allowable tax deduction in Australia.

All membership fees include: joining fee, first year's annual subscription and processing fee.

MA respects the privacy of your personal information. Personal information is collected on this form for the purpose of maintaining the membership database and provision of services. Click here to view our Privacy Policy in full.

 

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Last Updated October 2012