Membership Registration Form

MEMBERSHIP FEE
Full price: $249 per month

Special Offer Price: (closes 1st February 2023)

Special offer: 1 Person
$99 per month (only $23 per week)
(save $150 per month)

Special Offer: Household (3 or more people living at the same residence)
$249 per month (only $19 per week, per person)

To get the special offer you must register and complete the direct debit request form by the 1st of February 2023.

The earliest you may join the community is the 1st of December 2022.
Choose your Membership*

Special Offer: 1 person $99 per monthSpecial Offer: Household $249 per month (each person must register separately)Full Price: $249

PAYMENT METHOD
- Direct debit (bank or credit card)
- No set up
- No cancelation fee
- No lock-in contract
- Cancel any time
Direct debit payments are set up through Pay Advantage for both debit and credit cards, it only takes 2mins to set up and you are ready to go.

Two simple steps:
- Step 1: Submit this form - When you submit this form you will be sent a direct debit request link to both your email and phone (as a text message) within 7 days of submitting the form.
- Step 2: Complete the direct debit request within 48hrs of receiving the link, otherwise the direct debit request link will expire.
- Members outside of Australia must use Visa or Mastercard.
You agree and understand the following:*

I agree to complete the direct debit request with 48hrs of receiving it.I understand if I live outside of Australia I must use my Visa or Mastercard when completing the direct debit request.

PERSONAL DETAILS
Email*
example@example.com
Phone*
Name*

First NameLast Name
Business Name (if applicable)
Payment reference for tax purposes: i.e. professional development, group coaching, etc. (if applicable) The default reference is: Self Intelligence Community Membership
DOB*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
What is your current job/career role?
Optional

Before completing this enrolment form, you agree to have read and agreed to all Terms and Conditions, Declaration of Choice and the Code of Conduct:
Agreement*

Yes, I have read and agree with the Terms and Conditions.
Signature*

Clear
Date*

DayMonthYear
Date
Consent by parent or guardian (clients under 18 years of age ONLY)

First NameLast Name
Signature

Clear
Date

DayMonthYear
Date

SELF INTELLIGENCE COMMUNITY