Application/Renewal of Membership Form

ABN 76 064 723 146

Fees are due on the 1st January each year

Please click in the appropriate box

I/we wish to become a member or renew my/our membership as an:

  I am a parent, MPS affected person, relative, professional,  friend,  organisation

Surname 1: First Name (ord. member):Title:

Surname 2: First Name (assoc. member):Title:

 Name of Organisation: 

Address:

Telephone Contact Number:     Fax: 

Email Address: 

Relationship to Affected Child eg aunt, uncle, friend, doctor

Name of Affected Child/ren:  DOB:

Syndrome:

Ordinary membership (1st family member or individual - one voting right) includes GST = $27.50

Associate membership (combined with ordinary membership for couple - two voting rights) includes GST = $33.00

Corporate membership (one voting right) includes GST = $220.00

Overseas membership -  please add the following amounts for postage:

For the Asia Pacific region, add $11.00

For the Rest of the World, add $15.00

Payment can be made by credit card, cheque or bank draft in Australian Dollars to Mucopolysaccharide & Related Diseases Society Aust. Ltd or to the MPS Society. 

Please forward your cheque/bank draft or credit card details on this form, together with the completed form to the National Office, MPS Society, PO Box 623, Hornsby NSW 1630 Australia.

Credit Card Details:

Card Number:       Expiry Date:

Name on Card: 

Cardholders Signature:_______________________________________________

Enclosed is my membership payment of  $

Enclosed is my donation of  $

Total Amount to be Debited to Credit Card:  $

  Please remove my name from the mailing list.