United Firefighters Union Victorian Branch Membership Application Form

United Firefighters Union Victorian Branch Membership Application Form
Tick One Option*

I am an Existing Member (Update my details)I am a New Member
Select Option

MrMs
MissMrs
First name Please print*
Last name Please print*
Date of Birth*

DayMonthYear
Date
Phone (Home)

Area CodePhone Number
Phone Mobile
Please enter a valid phone number.
Address*

Address

Street Address Line 2

SuburbState / Province

Postal / Zip Code
Postcode*
State
Email*
Personal Email Address
I hereby apply to become a member of, and agree to be bound by, the rules of the United Firefighters Union of Australia. Ifurther assert that I am willing to assume all the rights and responsibilities attaching to such membership.
Signature*

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Date*

DayMonthYear
Date
WHERE YOU WORK
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I Work Full TimeI Work Part Time
Employer*
Rank or work classification
Work location
Work phone
Registered or payroll number*
Zone Platoon
UNION MEMBERSHIP
I authorise United Firefighters Union to arrange for funds to be debited from my account at the financial institution identified below. This authority shall stand until I notify United Firefighters Union of cancellation.
Signature*

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Date*

DayMonthYear
Date
YOUR BANKING/PAYMENT DETAILS
Tick One Option*

Pay by Direct Debit RequestPay by Credit Card Request
Option A: Direct Debit Request
Bank
Account name
BSB Number
Account number
Please complete bank details as authorised and return to United Firefighters Union by pressing the submit button below.
Option B: Credit Card Request
Select Credit Card Type
Name on card
Card Number
Expiry MM/YY
CCV #
Your credit card will be automatically debited each month.

Payments by cheque can be sent to UFU, 410 Brunswick St, Fitzroy 3065
Office Use Only
Entered
BCOM
Welcome Letter
Banking Details Activated
Should be Empty:

United Firefighters Union Victorian Branch Membership Application Form

WHERE YOU WORK

YOUR BANKING/PAYMENT DETAILS

Office Use Only