Membership

Application:	New Renewal
Date:
Name:
Date of Birth:
Partners Name:
Address:
Phone:
Mobile:
Email:
Type of Amputation:
Reasons for Amputation:
Hobbies and Interests:
Membership Fees	$25 Organisations $15 Adult single $20 Families/Pensioner Families $10 Single Pensioner/Student
*Membership fees and Donations more than $2.00 are tax deductible*
I would like to make a donation of:
	I do not wish to become a member at this time but would like some further information.