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	CISS Membership Application Form Date: _______________ Name:___________________________________________________________ Address:_____________________________________________________ _____________________________________________________ Postcode: ________ Country:______________________ Email address ____________________________________________ Home Phone:_______________ Fax: _____________________ Work Phone:_______________ Fax: _____________________ Occupation:________________________________________________ How can we help you?____________________________________________ ____________________________________________ How can you help us?____________________________________________ ____________________________________________ Subscription rates (includes 6 newsletters): Single $50, Double $60 $___________ 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. Alternatively you can fax the form together with credit card details to 02 9906 2189 Credit card type: ______________________________________ Credit card number: ___________________________________ Expiry date: __________________________________________ Name on card: _______________________________________ ----------------cut-here-and-paste-address-on-envelope--------- The Cancer Information & Support Society 6/56 Chandos Street St. Leonards NSW 2065 AUSTRALIA
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CISS Membership Application Form

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