General Membership - Queensland Alliance

Organisation Details
Organisation Type*
- Government
- Private Company
- Incorporated Association
- Not-for-Profit Organisation
- Non-Governmental Organisation
- Cooperative (Incorporated)
- Public Company
- Company Limited by Guarantee
- Community Group
Organisation Name*
Trading Name (if applicable)
ABN/ ACN*
Office Phone Number*
Website
Office Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Postal Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Do you have any other Offices in QLD?*
Contact Details
Member Representative Name (preferably CEO or Executive Level)*
Prefix First Last
Position*
Mobile Number
Email*
Member Representative Proxy*
Prefix First Last
Position*
Mobile Number
Email*
About Your Organisation
Organisation Target Population*
- 0 - 12 years
- 12 - 26 years
- 18 - 65 years
- Aged
- Aboriginal / Torres Strait Islander
- Culturally & Linguistically Diverse (CALD)
- LGBTIQ
- Non-specific / All
- Youth
Other (please specify)
Main Source Funding*
- Public fund raising
- Membership
- Fee for Service
- Community donations
- Philanthropic
- Government
- Non-funded
- NDIS
Other (please specify)
All Area(s) of Operation*
- Brisbane Metro North
- Brisbane Metro South
- Gold Coast
- Sunshine Coast
- Townsvillle
- Central Queensland
- Central West Queensland
- North West Queensland
- South West Queensland
- West Moreton
- Cairns & Hinterland
- Darling Downs
- Mackay
- Torres & Cape
- Wide Bay
Other (please specify)
Does this Organisation provide services in regional, remote or rural areas?*
Programs & Services Provided*
- Accommodation Support
- Alcohol & Other Drugs
- Carer Support &/or Respite
- Clinical Services
- Community Inclusions
- Independent Consumer Advice
- Counselling - Group/Individual
- Disability Support
- Employee/er Support
- Employment/ Work Readiness
- Financial
- Forensic Orders
- Homelessness
- Housing Support & Tenancy
- Independent Advocacy
- MH Awareness
- Peer Support
- Perinatal
- Prison & Transition
- Refugee Support
- Residential Rehab
- Service Coordination
- Social Enterprise
- Suicide Prevention
Condition Specific (please specify)
Other (please specify)
Membership Fees
Membership Fees (renewable annually on 1 July - GST exclusive)*
- Organisations with no annual income ($50 Membership Fees)
- Organisations with an annual income up to $500K ($175 Membership Fee)
- Organisations with an annual income up to $1M ($275 Membership Fee)
- Organisations with an annual income between $1M and $3M ($700 Membership Fee)
- Organisations with an annual income between $3M and $6M ($1,400 Membership Fee)
- Organisations with an annual income between $6M and $10M ($2,800 Membership Fee)
- Organisations with an annual income over $10M ($4,200 Membership Fee)
An invoice will be issued following receipt of completed membership form
Declaration*
- I have read, understand and agree with the Alliance Rules
Name
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New Organisation Membership Application

Organisation Details

Contact Details

About Your Organisation

Membership Fees

An invoice will be issued following receipt of completed membership form