CMSA Individual Membership Application

CMSA Membership Application

Individual or Principal Member of Corporate should complete this form, then print and mail/fax to CMSA

Case Management Society of Australia Ltd.

ACN. 130 205 284 ABN: 53 782 362 507

PO Box 1228
Castle Hill NSW 2154
Phone: 02 8850 5447Fax: 02 8850 5447

Email: cmsa@cmsa.org.au

Please complete the following information exactly as you desire it to be included in the CMSA Membership Directory

Please print legibly

New Membership Renewal

Preferred mailing address:

Home Work

Name

Date

First Last

Qualification(s)

Email

Mailing address

Suburb

State

Postcode

Country

Employer

Job title

Employer address

Suburb

State

Postcode

Work Phone

Fax

Which of the following best describes your special interest? (Tick all that apply)

Education

Acute care

Community care

Corrections

Disability services

Employment

Insurance

Mental health

Protective services

Rehabilitation

Other

Number of years in CM:

0-3 4-6 7-10 Over 10

Membership dues for CMSA are

Individual: $267 per year (inc GST)

Associate/Full-time Student: $190 per year (inc GST)

Corporate: Level 1 $1442 per year (inc GST) Level 2 $2310 per year (inc GST) Level 3 $3956 per year (inc GST)

TAX INVOICE

Method of payment

Cheque

or money order (enclosed) Amount enclosed $

Australian dollars)

Cheques should be made payable to "CMSA"

Credit Card	Card Type : Visa Mastercard
Card Number
Expiry Date	/	CardHolder Name
Signature

FOR OFFICE USE ONLY:

Date received;..............................	Receipt number:......................
Date banked................................	Date receipt sent......................