LES Membership Application Form

LES Membership Pricing	Jan-Mar	Apr-Jun	Jul-Sep	Oct-Dec (inc. following year)
Professional Australian Resident (inc. GST)	AU$260	AU$195	AU$130	AU$260
Professional NZ/International	AU$245	AU$183.75	AU$122.50	AU$245
Student (inc. GST)	AU$120

Personal Information

Membership:

Professional

Student (Proof of ID must be supplied)

Full Name:

Title:
First:	Last:

Job Details:

Job Title:

Employer/Firm:

Address:

Country:
Postal Address:	Suburb:
State:(leave blank if n/a)	Postcode:(leave blank if n/a)

Contact Details:

Phone: (include international dialling code)

Email:

Website:

Website Address:

Tell us how you heard about LESANZ:

Please select one:

Other Details:

Professional Category/Role:

Industry Sector/Business Focus:

Young Members Taskforce:
Are you eligible for the LESI young members taskforce? (To be eligible you are under the age of 40 in 2010)

Consent:
I agree my personal info can be included in the national Membership Directory by LESANZ and disclosed to members of LESANZ.

Payment Details:

Credit Card (Visa and Mastercard only):
Card Type: Name on Card: Credit Card Number: Expiry Date: /
Cheque: I will post a cheque made out to: LESANZ Inc
EFT: Arrange electronic funds transfer to the LESANZ account
Account Name: Licensing Executive Society of Aust & New Zealand BSB: 083 064 Account Number: 68553 6915	Bank: Bank of New Zealand Address: Melbourne office, 271, Collins Street, Victoria 3000 Swift Code: NATAAU3304B

*All transfer charges are to be paid by member/attendee.
*Please use surname in description of transfer for reconciliation and email the Secretariat with details of transfer

Process: Please check your email address is accurate as a tax receipt will be emailed to you immediately upon processing.

Total Amount:

Only click the Process button once. It may take a minute for your order to be processed. If you click again, you will be charged multiple times and sent multiple bookings.