APPLICATION FOR MEMBERSHIP

 

 

Name:

   (Please enter your fullname here)
       
  Address:  
      Suburb      Postcode
       
  Telephone/TTY:        Mobile:       Fax: 
       
  Email:  
       
       
  My focus as a member is:

Family member/advocate for a client of Senses
 Service Provider
 Client of Senses
 Supporter of Senses Foundation
 Other (Please specify)

   
  Alternate format required for publications:

Braille
 Large Print
 Audio Tape
 Other (Please specify)

   
   
  PAYMENT
   
  I will post $10 (cheque or money order only) to Senses Foundation, PO Box 143, Burswood WA 6100.
   
  Please debit my credit card:
 

 
 

Name of Credit Card Holder:

  Card Number:      Expiry Date: (mmyy)
   

Important: Please check your details before you click on the Submit button. Thank you.