HeadsUp Kippax - Membership Registration

HeadsUp Kippax Inc - Membership Application

Complete the form below to join the Association.
Our constitution requires that new members be being proposed and seconded by other members of the Association who can state that they personally know the Applicant.

If you do not know any members, contact us by clicking here and we will advise some suitable names or just enter the names shown in grey in the fields.

Joining Fee is $20.00 (waived until 31 December 2019) with annual subscriptions of $15.00 per year. The membership year is from 1 July - 30 June and your Joining Fee includes membership until the end of the June following your application.

We accept payment by credit card (Visa or MasterCard) which is processed instantly or you can make a payment using electronic banking, by cheque or in person at our shop: 2/12-16 Hardwick Crescent, Holt ACT 2615. All payment details will be in the email you receive after completing this form.
Name*
Email*

Confirmation Emailexample@example.com
Daytime phone number*
Mobile phone number
Address*

Street Address

Street Address Line 2

SuburbState/Territory

PostcodeCountry
Proposed by*
Seconded by*
Please select how you wish to pay:*

Instant (Credit/Debit card)Offline (Internet banking, cheque or in person)
Instant Payment*
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HeadsUp Kippax Joining Fee$ FreeAUD

HeadsUp Kippax Annual Membership Fees$15.00AUD

No of extra years

Total $0.00AUD
Joining Fee (Waived - normally $20.00)*

Yes
How many years extra membership? ($15.00 pa)*
Total amount to pay ($A):
Enter the message as it's shown*
Should be Empty:

HeadsUp Kippax Inc - Membership Application