Helpline 0800 650 659 continence nz

Join Continence NZ

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 WITHHOLD MY ADDRESS for any purposes other than issuing of news letters and association business, in line with the Privacy Act of New Zealand
   
Individual/company Member subscription $50.00
Organisation Member subscription $250.00 (see note above)
Individual Lifetime Membership $300.00
PAYMENT DETAILS.  
Payment by Cheque:

Note: Membership includes a subscription to the Australian/NZ Continence Journal, discounts to our education days, quarterly newsletters and the right to apply for educational funding after you have been a member for three consecutive years.

Please print this form and post with payment to: Continence NZ, PO Box 254, Waiuku 2341 or

direct credit to Continence NZ 02 0152 0000448 00 

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