TITLE: Dr Mr Mrs Ms Miss Other

SURNAME: ………………………………………………………

FIRST NAME: ………………………………………………………

ADDRESS: ………………………………………………………………………

……………………………………………………….

E-MAIL ADDRESS : ……………………………………………………….

PHONE NO: Home: ……………………………………….

Business: ………………………………………..

o Membership fee of $10.00 (includes GST) is enclosed for new or renewal of membership

o I wish to be on the mailing list for Newsletters and other information

o I would like to receive my Newsletter via e-mail.

o I am willing to supply the Association with information to assist with its
endeavors to help the HD community.

o I would like to become involved with the work of the Association

o Please tell me how I can make a bequest to Huntington’s Tasmania.

o Enclosed is a donation of $…………………..towards the work of Huntington’s Tasmania.

Your personal details are held under a secure password and will not be disclosed without your permission

Please return with your remittance to:

Treasurer
Huntington’s Tasmania
PO Box 1168
BURNIE Tas 7320