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

We encourage you to complete all form fields so that we can reach you with timely information.

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.

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*

*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.

*In which case you must satisfy the Board that you agree to the objects of the Company as outlined here: https://bit.ly/ObjectsOfCompany

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, how can you demonstrate a close connection to the area serviced by the Company? (Select all relevant)

Current or prior residence within the area serviced by the CompanyEmployment or affiliation with organisations in this areaClose and continuing family connections

To make membership fee payment easier for you, we can invoice for three or five years. What would you prefer? *

1 year3 years5 years

Signature of Applicant *

Clear

Date *