INVOICE
WOUND MANAGEMENT ASSOCIATION OF VICTORIA INC MEMBERSHIP FORM ABN: 42 304 529 967
Date:
Type of Membership
Membership Type*:	Full: $100.00 Corporate (Trade): $180.00 Full Time Students: $50.00
Personal Title*:	Mr Ms Mrs Miss Dr Prof
First Name*:
Last Name*:
Employer*:
Position*:
Private Details
Street Address*:
Suburb*:
Postcode*:
State*:	ACT NSW NT QLD SA TAS VIC WA
Phone:
Mobile:
Business Details
Address:
Suburb:
Postcode:
State:	ACT NSW NT QLD SA TAS VIC WA
Phone:
Fax:
Email Address:
ABN:
Please indicate if you are willing to have your name placed on a company mailing list
Yes  No
I agree and accept the rules & by-laws of the association:
Yes  No
Cheque / Cash / Money Order can be sent to:
Wound Management Association of Victoria Inc 351 Park Street South Melbourne, Victoria 3205