Join NZCA

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
ON RECEIPT OF THIS APPLICATION YOU WILL BE SENT A GST INVOICE.
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 and the right to apply for educational funding. Please print this form and post with payment to: NZCA, PO Box 270, Drury 2247 or direct credit to NZ Continence 02 0152 0000448 00 Or

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