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Member Renewal Form
Member Renewal Form
2022-23 Membership Renewal
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*
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Full name or Business/Organisation name
*
This is the membership holder. A receipt will be issued in this name. Please specifically identify your organisation or full name in this field. If you are a person with disability, please provide details below.
Contact person (may be same as above).
First name
*
Last name
*
Email (required)
*
Enter Email
Confirm Email
Website (if business)
Please enter a valid Website URL (e.g. https://www.idainc.org.au)
How did you hear about Integrated disAbility Action (IdA)?
If you are a person with a disability, what disability to you have?
Membership category
*
Please select the one that best applies to you:
Please select the one that best applies to you
Concession Card Holder ($10 inc GST)
Individual ($15 inc GST)
Family ($20 inc GST)
Corporate ($150 inc GST)
Would you like to add a donation?
Yes
No
Optional donation (enter amount):
Yes, I would like to make a donation. (Donations over $2 are income tax deductible.)
Total
Payment method
*
Direct Debit Account Name: Integrated disAbility Action Inc BSB 633-000 Account No:138752894 Please use surname as reference.
Cheque - Please make cheque payable to Integrated disAbility Action Inc
Credit Card - enter your details below
Credit Card
MasterCard
Visa
Supported Credit Cards: MasterCard, Visa
Card Number
Expiration Date
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Month
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Year
Year
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Security Code
Cardholder Name
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