First Nations Eye Health Alliance (FNEHA) Membership Application Form
Name
First Name
Last Name
Email
example@example.com
ABN (if organisational application)
Job Role (optional)
Organisation (optional)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I identify as:
Aboriginal
Torres Strait Islander
Aboriginal and Torres Strait Islander
Non Aboriginal and/or Torres Strait Islander
Please indicate which type of membership you would like to apply for:
Full Member - Aboriginal and/or Torres Strait Islander individuals working in, studying or interested in eye health (Free)
Associate Member - Aboriginal and/or Torres Strait Islander community-controlled organisations (Free)
Friends of FNEHA - Non-Indigenous Individual ($220 ex GST* per year)
Friends of FNEHA - Non-Indigenous Organisation ($1,100 ex GST* per year)
Signature
Date
-
Month
-
Day
Year
Date
Please note: All membership applications are sent to the FNEHA Advisory Board for endorsement. Once endorsed, you will be sent a confirmation email and invoice (if applicable) to pay for your membership.
By clicking submit, you declare all information on this form to be true.
*Please note GST is to be applied to the amount
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