Any adult interested in furthering the objectives of the Association is eligible for membership. Applicant Title: Mr Miss Mrs Ms Name: Contact Details Street:   Suburb:   State: VIC NSW TAS QLD WA SA NT ACT Postcode: Phone: Fax: Other Adults Included in Application The annual fee for membership is $20. A Household subscription for $30 is available where more than 1 adult family member living at the same address wishes to join. Please list the names of other adults to be included with this membership: 1) 2) 3) 4) Application Details - Please check box(es) below I hereby apply for single membership ($20 enclosed) I hereby apply for household membership ($30 enclosed) I cannot pay fees but wish to receive newsletters. Please delete my name from your membership list. I am a professional working with HD families and would like newsletters.* *Profession: *Workplace: Payment Details Membership Fee Enclosed: $ Donation Enclosed: $ Total Amount Enclosed: $ Signed:_______________ Date:__/__/____ Fill out this form then PRINT it and send it to: Australian Huntington Disease Association (Vic) Inc PO Box 60, Holmesglen, Vic, 3148.