CONSENT TO MEMBERSHIP FORM 30b – Associate Member

CONSENT TO MEMBERSHIP FORM 30b – Associate Member (Organisational)
Section 120(1) Corporations Act 2001 (Cth)
This form is used by organisations in application for Associate Membership of Autism SA. Please complete and return with payment
to Autism SA at the mailing address above. The application will be considered by the Board in accordance with Autism SA
Governance Policy 10 – Membership. To apply for your own Personal Associate Membership, please complete Form 30c instead.
Organisation Name:
Street Address:
Suburb:
Postcode:
State:
Suburb:
Postcode:
State:
Postal Address:
Contact Person
Title:
Name:
Position:
Please tick this box if you do not wish
to receive regular updates via email
Email:
Telephone:
Fax:
AUTHORISATION:
I consent to and request that Autism SA appoint the organisation named above as an Associate Member of the Autism
Association of South Australia (Autism SA) and certify that I am authorised by the organisation to give this consent.
I understand that an Annual fee (currently $88 per year inc. GST) is payable.
This application is unconditional and I authorise Autism SA to register the Organisation named above as a member and agree
to be bound by its Constitution. I understand that by agreeing for the Organisation to be a member of Autism SA I also provide
a guarantee of $1.00 in respect of the membership which only needs to be paid in the event of the company winding up.
Autism SA will be notified in writing by the organisation of any change to the above details within one month of the change.
Signature of Authorised Person:
Date:
Print Name:
PAYMENT DETAILS
Associate Membership (Organisational) inc. GST
I would like to make an optional tax deductible gift of
Paid by
VISA
Cheque
$20
Money order enclosed
MASTERCARD Number:
Full Name on Card:
$10
Expiry Date:
$60
$
88.00
Other amount:
$____.00
TOTAL
$____.00
Invoice to the contact person above
-
/
CVV:
Note for Payments by Invoice: If you choose the ‘invoice’ option above, Autism SA will send an invoice to the nominated contact. Once the
invoice has been paid, the membership application can be considered.
Privacy Statement: Your privacy is important to us and we are committed to the ethical collection and handling of your personal details. We’d
like to keep you informed of our activities but if you do not wish to be contacted in the future, please tick the box and return this form to us.
GOV F30b – May 2015