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Membership form




New member: please enrol me as a member of the PTUA.
Renewal: please renew my PTUA membership.
    * indicates mandatory field.

Title
Given name *
Family name *
Organisation
Address *
Suburb/town *
State *
Postcode *
Telephone * (Home)
(Work)
(Mobile)
Email *
Confirmation will be sent to this email address
 
I would like to receive the PTUA newsletter:
by post
by email
 
How did you hear about the PTUA?

Select membership type *
  1 year2 years
Bronze (Regular) $25 $40
Silver (Donor) $50 $80
Gold $100 $175
Family / Household $50 $80
Concession $12 $20
Community group $50 $80
Corporate $500 n/a
I would also like to make a donation: $