Application Form for
Health Consumers of Rural and Remote Australia
TAX INVOICE
ABN 68 480 848 412
Please print this form and return it with payment to Health Consumer of Rural and Remote Australia, PO Box 280 Deakin West ACT 2600.
There are two membership classes of HCRRA
- Full membership - cost $11 (inc GST)per financial year - a person is qualified to be a full member (with voting rights) if the person is a consumer, defined as a person living in a rural community who is not employed in the delivery of a health or welfare service.
- Associate membership - cost $22 (inc GST) per financial year - a rural health unit is qualified to be an associate member (with no voting rights).
I wish to become a member of Health Consumers of Rural and Remote Australia
Name: _____________________________________________
Address: ___________________________________________
___________________________________________________
State: ________________________ Postcode: ______________
Telephone (w): ________________________ (h): ___________________________
Fax: _________________________ Email: ________________________________
Area/s of interest ______________________________________
___________________________________________________
I would be interested in becoming a consumer representative (yes/no): ______
Category (please tick one):
_________
Full
$11 (inc GST) per year
_________ Associate $22 (inc GST) per year
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