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Membership Application Form

Full Name:
Address:
Suburb:
City:
Phone:
Fax:
E-Mail:

Please indicate your category of interest by selecting the appropriate group :
This information from health professionals would be helpful for us to target our campaigns and is retained anonymously.
Are you employed by a DHB?
Are you self-employed or in private practice?
Are you employed in residential care/hospital?
PLEASE WITHOLD MY ADDRESS for any purposes other than issuing of news letters and association business, in line with the Privacy Act of New Zealand
ON RECEIPT OF THIS APPLICATION YOU WILL BE SENT A GST INVOICE.
Individual/company Member subscription $25.00
Organization Member subscription $125.00 (see note above)
Individual Lifetime Membership $250.00
PAYMENT DETAILS.
Payment by Cheque:

Note: Membership includes a subscription to the Australian/NZ Continence Journal Please print this form and post with payment to: NZCA, PO Box 270, Drury 2247.