ATSICHS Brisbane Membership Application Form

ATSICHS Brisbane is Queensland’s longest-serving Community Controlled Health Service, formed by a small group of community members and health professionals in the early 1970s. It is now one of the largest community organisations in Queensland. We rely on the support of our members to ensure our services continue to meet the needs of our community.

Applicant Details

Please note we can only progress your application if you provide clear, complete contact details below:

Name *

Street address *

City *

State *

Postcode *

Phone Number

Mobile Number *

Email Address *

DECLARATION

MEMBERSHIP ELIGIBILITY

By applying for membership, I agree to:

Comply with the Company Constitution and Member Charter;
pay an annual membership fee of $1 per year*; and
my personal information being included on the Members’ Register and used for Company Member communications.

*If membership is approved, then a $1.00 per year membership fee is to be paid via bank transfer and renewal becomes due on 1 July annually.

I hereby apply for membership to the Aboriginal and Torres Strait Islander Community Health Service (ATSICHS) Brisbane Limited. Please select one of the following to indicate your descent: *

AboriginalTorres Strait IslanderAboriginal and Torres Strait IslanderNot of Aboriginal and Torres Strait Islander descent*

*In which case you must satisfy the Board that you agree to the objects of the Company as set out below.

Do you agree to the objects of the Company? (Please elaborate)

Do you live within the area serviced by the Company? (for example: Brisbane or Logan) *

YesNo

If NO, can you demonstrate a close connection to the area serviced by the Company?(For example: previous residence in the area serviced by the company, employment with local organisations or close family connections in the area)

Signature of Applicant *

Clear

Date *

Name of ATSICHS Brisbane member proposing (if any)

Signature of proposing member

Clear

Date