AUSTRALIAN AND NEW ZEALAND SOCIETY OF THE HISTORY OF MEDICINE INC.
Reg No. A003154W          ABN 88 095 106 769                                   

APPLICATION FOR MEMBERSHIP 2006
(Please click on the appropriate check box and type in the requested information,
print the form out using the print function of your web browser, then mail it as described below)

Title: Prof / Dr / Mr / Mrs / Ms Other:

Name/s:

Address: (including Department if applicable)


Postcode:
Telephone:
email:

Please enclose the following payment

Annual subscription (this includes newsletter and journal).

Concession subscription for fulltime students and pensioners (this includesnewsletter and journal).

Household subscription (2 people only, this includes newsletter and journal).

Institutional membership (this includes the journal and newsletter).

Institutional membership (this includes the journal only).

$55.00


$25.00


$70.00


$95.00


$80.00
Total $

Concession or student card number:    

Please make cheques payable to: Australian and New Zealand Society of the History of Medicine
OR you may pay by credit card
Please circle:         Bankcard         Mastercard              Visa

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Expiry date: /

Name on card:

Signature: ______________________________________
   
Send by mail to:
the Membership Secretary ANZSHM
PO Box 4092
The University of Melbourne Post Office
Victoria, 3052

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© 2007 ANZSHM

Created on: June 2000
Last modified: January 2008