Minerals Council of Australia - Associate Member Application Form

Nominated representative
An Associate Member should nominate a representative to attend meetings of the MCA and generally exercise all rights of membership. A member may change their representative nominee by written notice to the MCA Company Secretary.

Please note that all applications go to the Board for approval and following that an invoice will be generated.
Full name of company *
Nominated representative's name *

First Name Last Name
Nominated representative's position *
Date of application *

Day Month Year
Date
E-Signature (please draw signature using your mouse or finger) *

Applicant details
Please provide details below to enable the despatching of information, meeting agendas and general correspondence.
Company name *
Company switch phone *

Area Code Phone Number
Company email *
example@example.com
Nominated representative's name *

First Name Last Name
Nominated representative's position *
Nominated representative's email *
example@example.com
Company street address *

Street address

Street address line 2

City

Post code
State *
Company postal address (If different from street address)

Street address

Street address line 2

City

Post code
State
Direct phone *

Area Code Phone Number
Assistant's name

First Name Last Name
Assistant's email
example@example.com
Assistant's phone

Area Code Phone Number
Please list any subsidiaries

Finish
Privacy Statement

By providing information on this form, I agree that it may be used for the purpose for which it is intended. It will not be used for any other purpose without consent. The information provided will be kept confidential.
I confirm that I have read and understood the details and requirements within this application *
Should be Empty:

Associate Member Application Form