Australian Cannabis Agency
Suiite 2, Level 35, 360 Elizabeth Street, Melbourne, VIC, 3000
admin@cannabis.org.au
www.cannabis.org.au
(+61) 421283826
New MEMBER Registration Form
Member Details:
Business
Company Name
ABN
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
E-mail
*
example@example.com
How did you hear about us?
*
Please Select
LinkedIn
Internet
Referral
Other
Please Specify
*
What role do you currently play in the Australian Cannabis ecosystem?
Suggestions on how you want to be involved with the not-for-profit
Would you be interested in sponsoring or speaking at our next event?
Yes
No
Maybe
Membership Type:
*
Bronze (Individuals Only) $150 AUD Annually
Silver $799 AUD Annually
Gold $2,750 AUD Annually
Platinum $4,990 AUD Annually
Diamond $9,950 AUD Annually
Consent
*
Completion of this form and submission does not constitute acceptance of your application. Australia Cannabis Agency Ltd reserves the right to review and where appropriate, reject applications at their discretion. Your membership commences upon receipt of your membership fee. Your membership includes a cannabis.org.au newsletter subscription, upon membership payment, you hereby consent to receive communications from us. You may unsubscribe at any time. Yes, I agree with the above.
Signature
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