Membership Application Form Member Sign Up 2018 - 2019 Is this a new membership or a renewal?*New MembershipMembership RenewalComplimentary StudentComplimentary SponsorName* First Last Email* Contact Number*Mobile Number*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country OrganisationOccupationIndustry Sector*AgribusinessBush FoodsDairyEducationForestryGrainsLivestockHorticultureFisheriesNatural Resource ManagementPoultryProfessional ServicesResearchSugarStudentWoolOtherFacebook 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)ComplimentaryEducational Institution*Student Number*If you do not have access to email, please select the postage & printing box to get 6 x fortnightly Members Updates and 4 x quarterly editions of The Buzz posted to you. Postage & Printing Donations Accepted Payment Options*Credit Card — Pay NowDirect DebitChequeComplimentaryThere 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 email@example.com Make Cheque out to Australian Women in Agriculture Post Cheque to PO Box 7387 Shepparton, VIC, 3632 Credit Card* MasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 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 firstname.lastname@example.org or phone 0407 269 692.