APANA^® Individual Membership Application Form

APANA^® is the Australian Public Access Network Association Inc. (ARBN 081 355 722, VRN A0026600C). Application for membership should be made by completing and signing this form and posting it to the address below. Applications for membership should be accompanied by a cheque or money order for the first year's membership fee and any other fee (where applicable).

Please see the separate Membership Fees document for fee details.

This form is for individual membership only.  Non-profit organisations wishing to apply for membership of APANA should use the Organisational Membership form instead. Organisational Membership application forms should not be submitted without first contacting the relevant region. Please see the contacts page for the appropriate contact details.

All correspondence should be sent to:

                        APANA Inc.
                        77 Gerzalia Dr.
                        George Town
                        TASMANIA  7253
                        

IMPORTANT: THIS FORM MUST BE RECEIVED WHOLE AND INTACT. DO NOT OMIT ANY PART OF THE FORM OR YOUR APPLICATION WILL BE REJECTED.

(Revision: 1.8 $Date: 2002/02/20)

PERSONAL AND CONTACT INFORMATION

As required by law (Associations Incorporation Act 1981 [Vic] and the Australian Securities and Investments Commission), this information will be permanently recorded in the membership database.

At all times any member of APANA and their guests will have access to your membership number, your name, the region you are a member of, whether you are a financial member or not, and your email address.

Please indicate the APANA Region you wish to join:
(Membership is limited to one APANA Region at a time)

Surname:

First Name(s):

Business Hours Telephone Number:

After Hours Telephone Number:

Postal Address: 




Existing E-mail address (if any):

Are you aged over eighteen?       Yes  /  No

LEGAL DECLARATION

This declaration is required before your application for membership of APANA can be processed. Please be sure that you have read and understood both the Rules of Membership and the Network Acceptable Use Policy, included with any supplied information kit or via the World Wide Web site listed below, before signing this declaration.

I certify that the above personal details are true and correct and that I have been provided with a copy of the APANA Rules of Membership and the APANA Network Acceptable Use Policy and that I agree to abide by the conditions contained in those documents along with any new or altered policies or conditions which may from time to time be determined by the Management Committee of APANA.

Signed ________________________________________        Date

GUARDIAN'S SIGNATURE (if applicant is under 18 years of age)

Signature of Parent/Guardian:

 
 
Signed ________________________________________        Date

Payment can ONLY be made by Direct Deposit at any branch of the Commonwealth Bank (cheque or cash) or by Electronic Funds Transfer to APANA's account as follows:

Account Name:	APANA Inc.
Bank:	Commonwealth Bank of Australia
Branch:	367 Collins Street, Melbourne
BSB:	063-000
Account Number:	1017 3911
Statement Ref:	(Please enter your surname.)

PAYMENT SLIP - APANA® Inc.

I deposited the sum of $_______ to APANA's Bank Account on --/--/----