PSORIASIS AUSTRALIA INC.
MEMBERSHIP APPLICATION FORM

Psoriasis Australia strives to assist people with psoriasis, or those wanting to know more about psoriasis, by providing beneficial information and support enabling educated decisions to be made on treatment choices and lifestyle changes.

Membership of Psoriasis Australia Inc. entitles the member to:

§         Quarterly newsletters with the latest information from within Australia and overseas

§         Access to information on specific aspects of psoriasis

§         Access to new product information and samples

§         Raising funds for psoriasis research

MEMBERSHIP RATES:

Full members	$25.00	*
Pensioners/children	$12.00	*

[* cheques are accepted]

Please send details to:

PSORIASIS AUSTRALIA Inc.
P.O. BOX 290 ASHBURTON VIC 3147

Name: _______________________________________
Address:______________________________________
_______________________________________________
State: _____________            Postcode:______________
Telephone:_____________________________________
PensionNo: ____________________________________

 You may pay by credit card via mail. Visa, Master Card and Bankcard only.

Name on card:__________________________________
Credit Card No: __  __ __ __   __ __ __ __   __ __ __ __
Expiry date: __ __/__ __

Donations $2.00 and over Tax Deductible