1. DATE OF
APPLICATION:
2.
APPLICANT'S NAME and CONTACT
DETAILS:
Name:
Address:Postcode:
Phone: Fax:
Email:
3. POST
SECONDARY QUALIFICATIONS:
4. TWO
NOMINEES: Must be members of the
Company
Nominee
1:
Name:
Address:Postcode:
Phone: Fax:Signature:
Nominee
2:
Name:
Address:Postcode:
Phone: Fax:Signature:
I agree to
observe all rules and regulations within the
Memorandum and Articles of Association of
Chiropractic Education Australia Limited.
I agree to uphold
the principles of the Company and to assist in all
ways to accomplish its objectives.
I agree to pay all
dues assessed according to the requirement of my
membership status.
I hereby declare
that all information given in this application is
true and I understand that any misrepresentation on
my part whether wilful or unintentional may cause
me to forfeit my membership of this
Company.
5.
SIGNATURE OF APPLICANT:
Date:
PLEASE RETURN
COMPLETED APPLICATION FORM, TOGETHER WITH YOUR
MEMBERSHIP FEE OF $55.00 TO:
Chiropractic
Education Australia,
Mail to P.O. Box 444 Frenchs
Forest NSW 2086 or Fax with Credit Card Details to:
(02) 9452 2387
Please note: Do not send credit card details over the Internet.
Card Type:
Mastercard
Visa
Card No.
Name on Card:
Exp. Date:
Signature: