ANZAOMS Research & Education Foundation and Trust

Application for Membership
Name:*

PrefixFirst NameLast Name
Company Name (if a corporation)
ACN/ABN (if a corporation)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Phone Number*
Types of Membership

1. Member

2. Corporate Member

Foundation Rules Governing Membership
1. A Member - a member must;
  1. Be an individual resideing Australia or New Zealand
  2. Be an active or retired Oral & Maxillofacial Surgeon
  3. Be a financial Member of ANZAOMS
  4. New Members:
    
    Have contributed to the Public Ancillary Fund over a period of five years or less, amounts totalling $5,000 or more.
2. A corporate Member must;
  1. Be a body corporate incorporated in either Australia or New Zealand; and
  2. Have contributed to the Public Ancillary Fund (and has commenced such contributions over a period of five years or less, amounts totallying $10,000 or more.
Membership Type Being Applied For - Please select one.*
Contribution
The total amount I wish to contribute to the ANZAOMS Research & Education Trust is:*
I would like to make payment of this amount:*

In one payment and I understand that I will be issued an invoice for the above amount.I would like to be invoiced for my first payment at 20% of my total contribution and I understand that I will then be invoiced annually in June each year for a further 20% of my total contribution, for a total of 5 annual payments.
Agreement
In the event of my admission as a Foundation and Trust Member, I agree to be bound by the Rules of the Foundation and Trust in force for the time being and understand that these Rules can be found on the ANZAOMS website Member Portal www.anzaoms.org
Signature (if signing on behalf of a company, I confirm that I am authorised to commit my company to this membership)*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Application for Membership

Contribution

Agreement