Membership Application Form
Dying with Dignity Victoria Inc Reg No. A0006974B ABN 80 591 186 892
All fields in bold are required
Step 1 of 3 — Enter Your Details
Title:
Dr Mr Mrs Ms Mr & Mrs
First Name:
Last Name:
Occupation:
Current Previous/Retired
E-mail:
A copy of your application will be sent to this address.
Street:
Suburb/Town:
State:
Postcode:
Phone:
(H) (W)
Membership Fee:
Click the appropriate membership type to add it to the shopping cart, then click the Back button to return here and continue. Membership fees include GST.
Please note that the annual fees below are pro-rata until June 30 2012, after which a full annual fee applies.
Annual...
(full annual $40/$60 from Jul 1)
(full annual $20 from Jul 1)
Lifetime...
Donation:
Donations are optional and are GST-free. Click a donation amount and then click the Back button to return here and continue.
You may add multiple values to achieve any total.
View cart contents
Step 3 of 3 — Apply and Make Payment
Submitting your application will take you to the shopping cart where you complete your payment by credit card.
Authority:
I/we request to become a member/s of the Society.
Already a member and just need to renew? Click here
Credit card transactions are made using a secure server.
DWDV accepts the following credit cards for on-line applications.
DWDV is a self-funded, non-profit organisation, relying on volunteers, membership fees and donations to continue its work for all Victorians.
Fees are deliberately kept low so any additional donation you are able to make also helps us greatly.
