NEW Membership Application 2017-2018
PLEASE COMPLETE ANY TICK BOXES, FILL OUT ANY BOXES IN CLEAR CAPITAL LETTERS AND SUBMIT FORM ONLINE OR PRINT OUT AND POST TO PO BOX BELOW
Tick? Box ??Graduate Women Qld Gold Coast Branch
Tick Box? ?? Gwq Inc Sub Branch : Southern Cross University Gold Coast Campus /
Graduate Women Qld Inc.
Personal Details
Title: / Given Name/s: / Surname:Date of Birth / / (optional) / Former Surname
Home Address:
Suburb: / State: Postcode:
Mailing Address:
Suburb: / State: Postcode:
Home Phone: ( ) / Mobile:
Preferred email:
Qualifications
Qualification: / Institution: / Surname: / Year:Qualification: / Institution: / Surname: / Year:
Civil Honours
Honour: / Details: / Year:Current Interests(Please tick as many boxes as apply)
Education / Environment / International Relations / Status of WomenSocial Activities / Security & Peace / Information Technology / Health & Welfare
Other(specify)
Please Note: Membership is based on financial year (i.e. 1 July to 30 June) Membership fees are due on 1JULY each year
TICK BOX Gold Coast Branch Membership Fee Southern Cross University Gold Coast Campus Membership Fee / $ 10.00
Note: The GWQ subscription includes GWQ Inc / AFGW / GWI affiliation fee Sub Total / $ 105.00
Branch Group Subscription AND/OR DONATIONS (Please select from option/s below)
Membership Fellowships Fund Inc Branch (includes GST) / $ 5.00
Fellowships Fund Inc Branch Scholarships Donation / $ 5.00
Gold Coast Branch / Sub Branch Bursary Donation / $ 10.00
GWQ Inc Bursary Donation / $ 5.00
TOTAL PAYMENT Total / $ .00
Payment Method
Cheque Money Order [Please make cheque or money order out to GWQ Inc Gold Coast Branch and post to Treasurer, Graduate Women Qld Inc Gold Coast Branch, C/- PO Box 1150 Southport Business Centre, Southport, QLD 4215.] Payment Amount $ .00Direct Debit Account Name: Graduate Women Qld Inc. Gold Coast Branch
Bank: Heritage BSB No: 638 - 070 Account No:6997201
If paying by direct debit, please record your name on the electronic payment slip.
Please send your Bank’s Confirmation Number and/or scan your Bank’s Confirmation and email to the Treasurer Graduate Women Qld Inc Gold Coast Branch at
Declaration: I, the undersigned, hereby apply for Membership of Graduate Women Qld Inc Gold Coast and/or Graduate Women Qld Inc Gold Coast Sub Branch at Southern Cross University Gold Coast Campus
SIGNATURE OF APPLICANT: ……………………………………………………...... Date: / /
Privacy Statement: GWQ Inc. Gold Coast maintains a database of names, addresses and other information relevant to membership of the Association and for the purpose of mailing information, publications, notification of events etc and providing services and benefits to members. A member may request a copy of personal information held by the Association.
Office Use only: Membership No: / Year first joined: / Receipt Issued: / / /