Membership Application Form

* Required

First Name *
Last Name *
Contact Number *
Address *
Suburb/City *
State *
Postcode *
Country *
Address *
Email Address *
Tick the appropriate box	I would like IMIS to provide the contact number above to people looking for an instructor I do not wish IMIS to provide my contact details to people looking for an instructor
Membership Level *	Professional Student Affiliate Fellow
Payment Information
Payment Method *	Credit Card
Name on Card *
Card Number *
Card Expiry *
Card Type *
CCV Number *	?
Amount *
DISCLOSURE *	By submitting this application I agree to the following: These terms are subject to any and all rights provided under Australian Consumer Law. For more information about consumer rights visit the Australian Competition and Consumer Commission website at www.accc.gov.au or view the Competition and Consumer Act and the Australian Consumer Law via www.austliiedu.au. Payments received are non-refundable for change of mind. Membership will be renewed at the same level each year on or as close as possible to the first of the month of renewal, the month of renewal being the month this form is submitted or the month membership was due if this form is being used to make a late membership renewal payment; utilising the payment details submitted with this form, upon enrolment or for other payments to the Infant Massage Information Service. If I wish to cancel, I understand and agree that a request to cancel must be submitted in writing no later than by the thirtieth of the month prior to the month this form is submitted. In submitting this membership application, I agree to uphold the standards and ethics prescribed by the Infant Information Service.