Doctors Reform Society - Joining Form

Unfortunately we do not have facility for electronic lodgement of forms at this time.  If you wish, email the national office drs@nlc.net.au  with your details and request an invoice be sent to you.  Alternatively, PRINT THIS PAGE, complete the questions below,  and then FAX to 02-9267-4393, or mail to Box 14 Trades Hall, 4 Goulburn Street, Sydney NSW 2000.

Name: ___________________________________________________________

Preferred Postal Address: ___________________________________________

_________________________________________________________________
 

Home Address: ____________________________________________________

__________________________________________________________________

Work phone number: ________________________________________________

Home phone number: ________________________________________________

FAX: _____________________________________________________________

Email:_____________________________________________________________

What is your current role in the health system? ___________________________

__________________________________________________________________

What prompted your interest in the DRS? _______________________________

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Membership category: ___________ Fees: __________________

Tick payment method: Send Invoice ___ Cheque attached ____ Credit card ___

For Credit card only: Issued by: ________ Expiry date: ______

Number: ________ ________ ________ ________
 

Signature:
Date:

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