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:___________________________

 

Organisation:___________________________________________________________

 

Address:______________________________________________________________

 

Ctiy/Town___________________________________________  Postcode:_________

 

Telephone:____________________________  Facsimile:________________________

 

Email:________________________________________________________________

 

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?________________________________________________

 

Signature________________________________________Date______________________