Associate Membership Application Form - MAIL OR FAX TO 07 3879 0933

This form is specifically designed for people who are not eligible for free membership and who wish to apply for Defcom Protectors Associate Membership. Complete your details and then print the form below before returning to Defcom with your credit card details, cheque or money order to DEFCOM MEMBERSHIP PO Box 4333 Forest Lake 4078. Please allow up to 28 days for delivery.

NB. This form is NOT to be used by Protectors members who are eligible for Free Membership Contact Defcom on 07 3879 0911 for assistance).

Personal Details
Title	Miss Mrs Ms Mr Dr
Initials
Surname
Postal Address
Town
Postcode
Contact Phone	(include STD)
Associate Categories and Fees
Type of Associate	Select Associate Category ________________________________________ SPECIAL 5 YEAR MEMBERHIP OFFER TPI Recipient Spouse/Partner of current FREE member Other member of the public
Annual Fee	$49.50 (inc. GST) SPECIAL 5 YEAR MEMBERSHIP OFFER
	$27.50 (inc. GST)	(a) Other member of the public
	$11.00 (inc. GST)	(b) TPI Recipient (c) Spouse/Partner of current FREE member
Payment Details (NB. $0.50 credit card fee applies)        Credit Card applications can be faxed 07 3278 4200
Payment Method	Select your payment method MasterCard Visa Card Cheque Money Order
Credit Card No	Please debit the annual fee to my credit card
Expiry Date
Cardholders Name
Signature
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