NTAHC Membership Form 2

Please fill in all details*

I am applying to become a NTAHC memberI am renewing my NTAHC membership subscription
* Members are required to renew their membership subscription annually on 1 July to maintain voting rights.

Please tick:
Membership type*

Ordinary $25.00Concessional $10.00Corporate $50.00Consumer representative - Free Membership
Your full legal name:
Your preferred name:
If your applying for an organisation, enter the organisations name below:
Your address:
P/Code:
Phone (W):
Phone (M):
Email address:*
example@example.com
Signature:

Clear
Date:*

DayMonthYear
New members only, please fill out who you are nominated by and seconded by:
Nominated by:
The nominating person must be a current member and know the person seeking membership
Seconded:
If you are renewing please leave the following two questions blank. For new Members tell us a bit about: Why do you want to be an NTAHC member?
For new Members: Tell us a little about yourself.
Please pay by credit or debit card via our new online secure Stripe account below.
Alternative payment options:

Alternatively you can pay by direct transfer into the following account: BSB 633000 Account 141677195 and email info@ntahc.org.au the payment receipt. Or please call 08 89447777 to arrange payment by cash or eftpos.
Membership type

Ordinary $25.00Concessional $10.00Corporate $50.00Consumer representative - Free MembershipDonation

Enter membership cost and card details, the system will email you a receipt. If you are paying directly into our account or at the reception by cash or eftpos please do not fill this next section out, we will receive your membership form and contact you.

AUDMember payment - Enter total amount you are paying by credit or debit card.

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

OFFICE USE ONLY:

Payment received and receiptedMembers details entered into Stakeholder list / databaseMembers added to outlook member’s distributionMember added to eNews distribution listMember notified of outcome
Should be Empty:

Please pay by credit or debit card via our new online secure Stripe account below.

Alternative payment options: