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Please print out and complete the following form and return along with
payment to:
Queensland Womens Health Network
PO Box 1855, Thuringowa Qld 4817
Date: _________________
Name: ________________________________________________________________________
Organisation
(if
applicable): _______________________________________________
Postal
Address: _______________________________________________________________
Phone: ______________________
(W) _________________________________(AH/Mobile)
Email: _____________________________
Website: __________________________________
Please circle appropriate membership type, listed below:
Individual unwaged/student
. $5.50
Individual waged
$11.00
Organisation
.
...
$33.00
My cheque/money order (made payable to Queensland Womens Health Network
Inc.)
is enclosed for $___________ to cover one financial year's membership (1
July to 30 June)
Do
you consent to your name being distributed for Network purposes? YES
NO
I/We
hereby agree to abide by the Purpose and Objectives of the QWHN
Signature/s................................................................................ |