ACTA Membership Application Form

Table of fees: (Australian dollars) Please read "About ACTA" before filling out this form.
-Ordinary Member  $15.00  (Annual Subscription)
-Associate Member $20.00  (Annual Subscription)

Please print out this membership form, fill in the relevant details and return with Chq/MO made out to ACTA Inc and post to:

 ACTA Inc.   PO Box 987, Inverell  NSW  2360

Title: Dr: Mr: Mrs: Miss: Ms._____ (circle one please!)

Surname:_________________________   Forenames:___________________________
Ctiy/Town___________________________________________  Postcode:_________
Telephone:____________________________  Facsimile:________________________
Please place tick in the appropriate space:
Ordinary Member__  (Chemically Effected)     Associate Member__   (ACTA Supporter)       
(If Ordinary Member, please enclose a letter detailing how you are chemically affected)
         Ordinary and Associate Members receive the quarterly newsletter UPDATE
Do you wish secrecy?
Yes__       No__        Enclosed:     Cheque__       Money Order__
(Payable to:  ACTA Inc. See table of fees above)   Value $________
Who introduced you to ACTA?________________________________________________
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