Member Application Form

Member Application Form

Electrical Trades Union of Australia, Victorian Branch
I, the undersigned, hereby apply to become a member of the CEPU, Electrical Division Victorian Branch, and I pledge myself to comply with the rules* of such union and any amendments or additions which may be legally made to such rules.

* Read terms and conditions, and our membership rules at: www.etuvic.com.au/terms
Name*

First NameFamily Name
Address*

Street Address

Street Address Line 2

SuburbState

Postcode
Email*
example@example.com
Mobile Telephone*
Please enter a valid phone number.Format: 0000 000 000.
MaleFemale
Date of Birth*

DayMonthYear
Date
Occupation*
Employer (as it appears on your pay slip*
Employer Address*

Street Address

Street Address Line 2

SuburbState

Postcode
YesNo
Signature*

Clear
Date*

DayMonthYear
Date
Apprenticeship Dates
Date Apprenticeship Commenced

DayMonthYear
Date
Date Due to Complete Apprenticeship

DayMonthYear
Date
YesNo
If Yes, which branch were you a member of?
Payment Method
Direct DebitCredit Card
BANK AND FINANCIAL CO-OPERATIVE DIRECT DEBIT AUTHORISATION
Date

DayMonthYear
Date
Name of Financial Institution at which your account is held
Address of Financial Institution at which your account is held

Street Address

Street Address Line 2

SuburbState

Postcode
Family Name or Company/Business Name
I/We
Given names
request you, until further notice in writing, to debit my/our account described in The Schedule below any amounts that the Electrical Trades Union, Victorian Branch (User I.D. No. 062881) may debit or charge me/us through the Direct Debit system.

I/We understand and acknowledge that:
1. The Financial Institution may, in its absolute discretion, determine the order of priority of payment by it of any monies pursuant to the Request of any authority or mandate.
2. The Financial Institution may, in its absolute discretion, at any time by notice in writing to me/us, terminate this Request as to future debits.
Signature/s (If a joint account, all signatures may be required)
Signature 1

Clear
Signature 2

Clear
Customer Address

Street Address

Street Address Line 2

SuburbState

Postcode
The Schedule
Name of account to be debited
BSB Number
Account Number
WeeklyFortnightly
Note: Direct Debiting is not available on the full range of accounts. If in doubt, please refer to your Financial Intitution.
Credit Card Payment
YESNO
Should be Empty:

Member Application Form

Apprenticeship Dates

Payment Method

BANK AND FINANCIAL CO-OPERATIVE DIRECT DEBIT AUTHORISATION

The Schedule

Credit Card Payment