Please print this form and post or fax it to the address shown below
HYPERBARIC TECHNICIANS AND NURSES ASSOCIATION
MEMBERSHIP APPLICATION
(Please Print Clearly)

(Circle one)...New Application ............. Renewal

Surname........................................................................Christian Name...............................................................

Postal Address......................................................................................................................

................................................................................................................................................

................................................................................................................................................

State............................ Postcode............................... Country............................................

Ph................................ Fax.......................................... E-mail.............................................

Occupation...............................................Note : The published list of members will only include Name, State and Country.

Type of membership applied for (circle one)

Full A$ 60 ..........Associate A$ 40 ......Note: Full membership is available to Technicians and Nurses Only
Corporate
Diamond A$ 5,000......Platinum Plus A$ 3,000......Platinum A$ 2,000......Gold A$ 1,000......Silver A$ 500

Company Name.....................................................................................................................................................

For full membership, please give - Current Hyperbaric Position..................................................................

Hyperbaric Unit.................................................................................. Date Commenced...................................

Payment Details (circle one).... Cash.............. Cheque............. Bankcard.............. Visa MasterCard

Card Number....................... /..................... /..................... /.............................

Name on Card................................................................. Expiry Date.......................................

Signature........................................................................... Date.......................................

Please make cheques payable to "Hyperbaric Technicians and Nurses Association"
Postal address
HTNA Membership
Hyperbaric Medicine Unit
Townsville General Hospital
PO Box 670, Townsville, Qld 4810
Australia

For further information contact
The Secretary HTNA on...Ph: 61 7 4781 9476.... Fax: 61 7 4781 9582....E-mail: HTNA@bigpond.com
Please note that membership is valid from 1 July to 30 June
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Office use only: Entered in data base Date……….............…Receipt No ......................... Date Sent .....................
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