AESSRA Inc.

Membership Form

for pdf version click here

For Australian residents only

Information provided on this form is confidential. Post this form with a cheque/money order to AESSRA Inc. PO Box 298, Ringwood, Vic 3134

Tick as applicable

__  New member      __ Renewal

__ Donation to AESSRA Inc. ……

__ Donation to AESSRA Research Fund ……

__ Keep my donation anonymous (If box isn’t ticked donors will be listed and thanked in Sensitivity Matters)

Donations of $2 and over are tax deductible

__ Hospital Guidelines for patients with Multiple Chemical Sensitivity $3.30 (includes GST)

__ Natural and Non-Toxic product guide $5.50 (includes GST)

TOTAL ………..

I agree to be bound by the Code of Conduct and Rules of AESSRA Inc. for the time being in force.

Signature ..............................................................

Date ......................................................................

(for further information see www.aessra.org/joinaessra)

Mr/Mrs/Ms/Miss ........................................……...

Address ....................................................……....

.................................……......Postcode ..............

Phone Number ....................................…………

Email ………………………………………………..

How many people in your family (including you) have chemical sensitivities? …...

How many people in your family  (including you) have food allergies or sensitivities? ……

Can you or your family help with any AESSRA activities?  YES/NO

………………………………………………………………....

Brochures

Please send me the following brochures to give people or put in health food shops, waiting rooms, libraries etc

Are you sensitive to chemicals?  

 __5    __10    __ 20  

What’s in your perfume, fragrances and scented products? 

__ 5    __ 10    __ 20  

Fragrance and Health   

__ 5    __ 10   __ 20