RMD Members Details Form

Retired Members Division - Membership Application
Name

First NameLast Name
Date Of Birth

DayMonthYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Phone Mobile
Please enter a valid phone number.
Email
Example - Russell@gmail.com
Reg #
Union Membership
I authorise United Firefighters Union to debit $10 from my account on sign up. I authorise for the United Firefighters Union to arrange for $10 to be debited from my account annually at the financial institution identified below. This authority shall stand until I notify the United Firefighters Union of my cancellation.

Acceptance: By signing and submitting this form I herewith agree to abide by the above payment arrangement.
BANK DETAILS
Direct Debit
Bank
Account Name
BSB
Account Number
Credit Card
Select Card Type

VisaMastercard
Card Number
Name on Card:
Expiry Date MM/YY
CSV (3 digits on the back of the card)
Is there any other information you would like to provide.
Please note this information is confidential, will be kept private and not shared within anyone without you or your family's consent.

Enquiries via Email to United Firefighters Union membership@ufuvic.as.au
Phone 9419-8811.
Signature:

Clear
Date

MonthDayYear
Date
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Retired Members Division - Membership Application