LES Membership Pricing

• Personal Information

• Membership Professional Student (Proof of ID must be supplied)
• Full name Mr Mrs Ms Dr Title First Last
• Job Title
• Employer/Firm
• Address
  Street Address
  Suburb
  State - (eg: VIC/ACT/NSW etc.)
  Postcode
  Afghanistan Albania Algeria Andorra Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe Country
• Phone (Country & Area code required)
• Email
• Web Site
• Professional Category/Role --- Please select --- MD/CE Engineer Operations Manager Business Development Technical/Scientist Sole Trader/Inventor Marketing Consultant GM/Commercial Manager Enterpreneur Student Patent/TM Attorney Lawyer/Solicitor Other
• Industry Sector/Business Focus --- Please select --- Agriculture/Forestry/Viticulture Import/Export Manufacturing Consumer Manufacturing Industrial Banking/Venture Capital Professional Services IP Asset Management Energy & Natural Resources Health and Life Sciences Sole Tader IT/Comms Technology Government Building & Construction Transport Other
• Are you eligible for the LESI young members taskforce To be eligible you are under the age of 40 in 2008.
• Consent I agree that my personal information can be included in the national Membership Directory by LESANZ and disclosed to members of LESANZ.
• Payment Method Cheque made out to: LESANZ Inc Electronic fund transfer:
  Bank: Bank of Zealand
  Address: Melbourne office, 271, Collins Street, Victoria 3000
  Account Name: Licensing Executive Society of Aust & New Zealand
  BSB: 083 064
  Account Number: 68553 6915
  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 Credit card
• Card Type
  Select Card Type Visa MasterCard
• Name on Card
• Credit Card Number
• Expiry Date
  Month 01 02 03 04 05 06 07 08 09 10 11 12  / Year 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
• $117.25

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