APANA^® Organisational Membership Application Form

Please note that all Organisation membership applications are subject to approval by the relevant regional committees. Please contact that committee for fees, special charges, conditions and a Tax Invoice (if you intend to claim Input Tax Credits), before returning this form.

APANA^® is the Australian Public Access Network Association Inc. (ARBN 081 355 722, VRN A0026600C). Application for membership should be made by completing and signing this form and posting it to the address below. Applications for membership should be accompanied by a cheque or money order for the first year's membership fee and any other fee (where applicable).

Please contact the appropriate regional committee for fee details.

This form is for organisational membership only.  Individuals wishing to apply for membership of APANA should use the Individual Membership form instead.

PLEASE NOTE:

Organisations wishing to apply for membership should first contact the closest APANA regional committee. Contact details can be found by sending e-mail to info@apana.org.au or under contact details on APANA’s home page http://www.apana.org.au/.

Cheques/Money Orders should be made payable to "APANA Inc." and sent to:

                        APANA Inc.
                        77 Gerzalia Dr.
                        George Town
                        TASMANIA  7253
                        

An email receipt will be sent to the address you provide below. In order to contain costs, printed receipts will only be sent via regular mail on request.

IMPORTANT: THIS FORM MUST BE RECEIVED WHOLE AND INTACT. DO NOT OMIT ANY PART OF THE FORM OR YOUR APPLICATION WILL BE REJECTED.

(Revision: 1.8 $Date: 2002/02/20)

PERSONAL AND CONTACT INFORMATION

The following information is required for APANA membership records and for us to contact you should the need arise. It will not be disclosed to third parties, without your written consent, except where required by law. Portions of this information will be recorded in our membership register which is available for public inspection, by law, upon request to the secretary.  Phone numbers will not be made available for public inspection.  Access to phone numbers will be restricted to APANA administrative personnel only.

As required by law (Associations Incorporation Act 1981 [Vic] and the Australian Securities and Investments Commission), this information will be permanently recorded in the membership database.

At all times any member of APANA and their guests will have access to your membership number, your name, the region you are a member of, whether you are a financial member or not, and your email address.

Please indicate the APANA Region you wish to join:
(Membership is limited to one APANA Region at a time)

Organisation Name:

Business Hours Telephone Number:

After Hours Telephone Number:

Postal Address:




Existing E-mail address (if any):

The organisation must nominate a person to be its representative in all dealings with APANA. This person will be responsible for ensuring that the organisation complies with all APANA rules, acceptable use and other policies and directions from the APANA management committees.

Representative's Name:

Business Hours Telephone Number:

After Hours Telephone Number:

Postal Address:




Existing E-mail address (if any):

The representative's information will not be available to people other than the APANA administrative personnel.

Please remember to include payment of the appropriate fee.

LEGAL DECLARATION

This declaration is required before your application for membership of APANA can be processed. Please be sure that you have read and understood both the Rules of Membership and the Network Acceptable Use Policy, included with any supplied information kit or via the World Wide Web site listed below, before signing this declaration.

I certify that the above personal and organisational details are true and correct and that I have been provided with a copy of the APANA rules of membership and the APANA network acceptable use policy and that I agree on behalf of the organisation to abide by the conditions contained in those documents along with any new or altered policies or conditions which may from time to time be determined by the Management Committee of APANA.

Signed ________________________________________        Date


Position ______________________________________

Payment can ONLY be made by Direct Deposit at any branch of the Commonwealth Bank (cheque or cash) or by Electronic Funds Transfer to APANA's account as follows:

Account Name:	APANA Inc.
Bank:	Commonwealth Bank of Australia
Branch:	367 Collins Street, Melbourne
BSB:	063-000
Account Number:	1017 3911
Statement Ref:	(Please enter your surname.)

PAYMENT SLIP - APANA® Inc.

I deposited the sum of $_______ to APANA's Bank Account on --/--/----