053

TAX INVOICE
ABN 82 958 634 724
AHSPO Inc is not registered to collect GST
Therefore AHSPO Membership Fees do not include GST

FULL / AFFILIATE MEMBERSHIP RENEWAL ONLY

Current 2010 renewal rate for Full & Affiliate Members is $60.00

Title	Surname	Christian Name

		Member Number [if known]


Name on Credit Card: Credit Card Type : Credit Card Number: Credit Card Expiry [MM/YY]: Note: Only Visa / Bancard / MasterCard are accepted

OPTIONAL - Complete the following fields to submitt changes to existing information. If no changes please skip this section and click submit.
Employer's Name
Present Position
Employer's Address

Suburb State Post Code
Preferred Mailing Address
Work Phone
Mobile
Fax
EMail Address

Please contact:

Aldo Santo
AHSPO Membership Officer

Postal Address:
C/- Supply Dept
Wonthaggi Hospital
Graham St
Wonthaggi, Vic 3995

Tel: 03 567 13160
E-Mail: aldo.santo@bcrh.com.au
Fax: 03 567 133 69

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