Qld Scleroderma Membership

Membership Application

1st July 2022 to 30th June 2023
Name

TITLE GIVEN NAMES SURNAME
ADDRESS
POST CODE
Phone Number

Area Code Phone Number
Email
example@example.com
MAIL OPTIONS

Email Postal
DATE OF BIRTH

Day Month Year
Date
Do you have Scleroderma?

Yes No I know someone with Scleroderma
Do you have Sjogren's or Raynauds Phenomenon?

Sjogren's Raynauds
Do you have any other autoimmune disease?
How did you learn about the QLD Association?
MEMBERSHIP - Family included

Flat rate ($30)
Donation
Total Payable
MAIL Please attach cheque or money order, payable to Scleroderma Assn. Of Qld Inc. PO Box 316, SALISBURY, QLD, 4107 BANK TRANSFER Scleroderma Assoc of QLD - BSB:638-070 ACC: 7271069 REF: Your Name
DECLARATION OF PRIVACY

The Scleroderma Association of Queensland Inc acknowledges and respects the privacy of individuals. This information is being collected for the purpose of processing your application, keeping you informed of upcoming events, information, and support programs, and assisting us to improve our services. You have a right of access to, and alteration of your personal information in accordance with the Act. Please direct inquiries to The Secretary at 0438 555 015.
Date

Day Month Year
Date
SIGNATURE

Clear
Telephone: 0468 801 021 email: info@scleroderma.org.au
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