GSA Membership Application Form

GSA MEMBERSHIP APPLICATION FORM

Genetics Society of Australasia, Inc.

The Genetics Society of Australasia, Inc. is a non-profit scientific organization established for the purposes of advancing the discipline of Genetics and of providing a forum for exchanges of information between geneticists in Australia. The society encourages all persons actively interested in Genetics to become members. Members receive all mailings, including information about Annual Scientific Meetings. Abstracts of papers presented at the Meeting are available to all members who are unable to attend via the internet or in hardcopy (upon request to conference organisers before meeting).

1. Details

Surname		Title
Other
Address


City		State
Postcode		Country
Tel.		Facsimile
Email

2. Privacy Question

May your telephone/email details be distributed on a GSA listing? YES NO

3. Membership Type

In addition to Honorary, Ordinary and Sustaining members, there are reduced rate members, which includes members not in full employment, overseas and retired members, and others, as determined by the Committee.

Please tick the category appropriate to your case:
	Normal dues	($50.00 per annum)
	Reduced dues	($20.00 per annum)
If you are claiming reduced rate membership indicate the category and reasons below.
	Student
	Signature of Supervisor, Department Chairman or equivalent is necessary for student rate
	Name
	Position

	Signature	............................................................
	Other
	Outline basis of claim for reduced rate if not a student

4. Payment

Please return the completed form and a cheque made out to "Genetics Society of Australasia Inc" or credit card information.

Cheque Credit

Bankcard Mastercard Visa

Cardholder's Name:

Card Number:

Card Expiry Date:

Cardholder's Signature: ..................................................

5. Send completed form and payment to:

GSA Subscriptions
13 Jeffery St
Mt Waverley VIC 3149

Cardholder's Name:
Card Number:
Card Expiry Date:

Cardholder's Signature:	..................................................