CISS Membership Application Form 				
Date:      _______________

Name:____________________________________________________________

Address:_________________________________________________________
           
_________________________________________________________________

Postcode:  ________ Country:______________________

Home Phone:_______________       Fax: _____________________

Work Phone:_______________       Fax: _____________________

Occupation:________________________________________________


How can we help 
you?_________________________________________________

    _________________________________________________


How can you help 
us?___________________________________________________

   ___________________________________________________


Subscription rates (includes 6 newsletters):
Single $40, Double $50      		$___________
                                    
Donation                    		$___________
                                   
Total 						$___________


Please print off this FORM and fill in the details. Include A cheque or postal order for the amount you wish 
to pay. Donations of $2 and more are tax deducible: Cert. No. AF 1595C SF 6971. All amounts shown are 
in Australian Dollars. Please make cheques payable to: The Cancer Information & Support Society. 

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   The Cancer Information & Support Society 
   6/56 Chandos Street                     
   St. Leonards NSW 2065                   
   AUSTRALIA