Qld Scleroderma Membership

SCLERODERMA ASSOCIATION OF QUEENSLAND INC.
Membership Application - NEW MEMBER

1st July 2021 to 30th June 2022
Name

TITLE GIVEN NAMES SURNAME
ADDRESS
POST CODE
Phone Number

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

Please tick if you would prefer correspondence to be MAILED (default is email)
DATE OF BIRTH

Day Month Year
Date
Do you have Scleroderma?

Yes No - If no, do you know someone that has Scleroderma, please state. ______________
Do you have Sjogren's or Raynauds Phenomenon?

No Yes (Please State) ____________________
Do you have any other autoimmune disease?
How did you learn about the QLD Association?
MEMBERSHIP OPTIONS

SINGLE ($25) FAMILY ($30)
Name of additional family member/s (must reside at the same address):
Donation for Research ($5 or more is tax deductible)
Donation for Administration Expenses
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.
SIGNATURE

Clear
Date

Day Month Year
Date
Telephone: 0468 801 021 email: scleroqld@gmail.com
Should be Empty:

SCLERODERMA ASSOCIATION OF QUEENSLAND INC.