Associate Membership - Queensland Alliance

Associate - Industry & Individual Membership
Are you applying as an Organisation or Individual?*
Organisation Name*
ABN*
Contact Name*
Prefix First Last
Individual Name*
Prefix First Last
Phone 1
Phone 2
Email
Postal Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Office Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Why are you interested in joining and supporting QAMH?
How did you hear about QAMH?*
- QAMH member
- QAMH team member
- Mental health alliance in my region
- Attended a QAMH event or meeting
- QAMH website
- Word of mouth
- Other
Associate Industry Membership Fee - $500 (GST exclusive - renewable annually on 1 July)
Associate Individual Membership Fee - $50 (GST exclusive - renewable annually on 1 July)
An invoice will be issued following receipt of completed membership form
Declaration*
- I have read, understand and agree with the Alliance Rules
Name
This field is for validation purposes and should be left unchanged.

Associate - Industry & Individual Membership