Membership
Please print off this page, fill out appropriatedly and post to the Secretary.
QUEENSLAND ACOUSTIC NEUROMA ASSOCIATION
INC.
MEMBERSHIP APPLICATION FORM
Name: .........................................................................................................................
Address: .....................................................................................................................
Phone:
Home ................................................
Work...............................................
Date of
Surgery/Treatment: .....................................................
Past/Present
Career: ...............................................................
Date of Birth: ............................................................................
What you would like from the Association and/or what you can offer the Association
......................................................................................................................................
......................................................................................................................................
$30.00 subscription fee to be attached
Membership is from 1st July to 30th
June.
(Membership for new members joining Q.A.N.A. as of the 1st April will
continue until 30th June the following year).
The subscription is per family, so your family/member/loved ones are eligible to attend meetings and functions.
Signature: ....................................................................................................................
Date: .............................................................................................................................
Please post form and cheque/money order made
payable to:
Queensland Acoustic Neuroma Association
Inc.
PO Box 254, Stones Corner, Queensland. 4120.
Website:- www.qana.asn.au
Email: qana@st.net.au
Thank you for your Application and Welcome to
Q.A.N.A.