Please click here if there is no Menu on the left or to break out of frames ACN 002847458 ABN 38529817275 Charity No:CC26453

MEMBERSHIP APPLICATION FORM

Please complete and print this form, then post with your cheque, money order or credit card details to Australian Tinnitus Association (NSW) Ltd, PO Box 660 Woollahra NSW 1350 OR Fax to (02) 8382 3333. Annual Full Subscription $30 + $5 joining fee Senior Annual Subscription $25 + $5 joining fee Pensioner Annual Subscription $20 + $5 joining fee (Note Financial Year 1st January to 31st December, all prices include GST) As a member you will get the following: · A Tinnitus noise tape (useful for family and friends). · A booklet titled "Beyond Silence" written by Kathy Challinor. · ATA Tinnitus related fact sheets. · A contact list of Tinnitus clinics, self help groups and other organizations. · A list of available books, relaxing tapes and videos sold through the ATA (View). · Our quarterly newsletter "Tinnitus Talk" (latest copy enclosed)

Details about yourself Title Select Mr Mrs Ms Miss Mme Lady Sir Dr Prof Colonal Full Name Address Town State Select NSW VIC QLD SA WA ACT NT TAS TAS Other Postcode Country Email Phone @ Select HOME WORK MOBILE FAX OTHER

Payment details Amount Select $35.00 $30.00 $25.00 Pension No. Seniors No. Donation (Donations over $2 are tax deductible) TOTAL Enclosed Select Cheque Money Order OR Please debit my Select Bankcard Mastercard Visa Card No Expiry Date Name on Card