EPLA Membership subscription form

Membership Application/Renewal (Required)

Existing member
New member

Membership type (Required)

Please select membership type. If you or your organisation is based in an outer metropolitan, regional country or interstate area. You are entitled to a 25% discount.

Individual $181.50
Student (F/T Course) $49.50 (please fill in course title below)
Corporate rate $660.00 (please fill in organisational names below)
Councils & Government Departments $363.00

Your E-Mail Address (Required)

Surname (Required)

Please enter your surname

Other Names (Required)

Please enter your first and other names.

Occupation

Please enter your occupation

Organisation

Please enter your organisation name

Position

Please enter your position

Postal Address (Required)

Please enter your postal address

DX Address

Telephone

Facsimile number

Mobile

Student F/T Course:

If you are purchasing a student membership please enter your course.

Organisational names

If you are purchasing membership for an organisation. Please enter the names (and email addresses) below.

Publish name?

Untick the box above if you do not wish your name to be added to our published membership list.

Please indicate your payment method (Required)

Cheque

Direct Debit

Credit Card

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Payment options:

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