Membership Application Form Member Sign Up 2018 - 2019 Is this a new membership or a renewal?*New MembershipMembership RenewalName* First Last Email* Contact Number*Mobile Number*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country OrganisationOccupationIndustry Sector* Grains Livestock Poultry Dairy Wool Horticulture Forestry Fisheries Sugar Bush Foods Natural Resource Management Professional Services Research Education Agribusiness Student Other Facebook URLTwitter HandleLinkedIn URLAge*Under 2020-2526-3536-4546-5556-65Over 65I do not wish to advise of my ageI authorise AWiA to send me regular communications, including a fortnightly Members Update and quarterly newsletter, The Buzz, plus any other official publications.* Accept I authorise the inclusion of my personal details on a membership list for distribution to other members. I understand that this list is the property of AWiA and is for members’ personal networking use only.* Accept Exclude me I understand that in the event that the company is unable to meet its debts and it is wound up, then I will contribute $5 towards that debt.* Accept As per Article 6 - Winding Up in Australian Women in Agriculture Memorandum of Association Membership Fee*1st July 2018 - 30th June 2019 $90.00 (GST inc)1st October 2018 - 30th June 2019 $67.50 (GST inc)1st January 2019 - 30th June 2019 $45.00 (GST inc)Full time student from 1st July 2018 - 30th June 2019 $30 (GST inc)Educational Institution*Student Number*If you do not have access to email, please select the postage & printing fee box to get 6 x fortnightly Members Updates and 4 x quarterly editions of The Buzz posted to you for additional $60.00. Postage & Printing Fee Donations Accepted Payment Options*Credit Card — Pay NowDirect DebitChequeThere is an additional 1.7% fee for credit card payments.Credit Card Fee Price: $ 0.00 Total $ 0.00 Westpac BSB: 035 621 Account number: 193 909. Use your full name as Reference. Email receipt to firstname.lastname@example.org Make Cheque out to Australian Women in Agriculture Post Cheque to PO Box 7387 Shepparton, VIC, 3632 Credit Card* MasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name Receipt Receipt Required Please note: A receipt for membership will not be issued until payment is received. Your membership may be tax deductible.For all enquiries, email AWiA Treasurer Maria Brown-Shepherd at email@example.com or phone 0407 269 692.