Name: ................................................................................................................................................
Address:.............................................................................................................................................
Telephone: ................................................. Facsimile
No: ...............................................................
Email: ................................................................................................................................................
Cheque
enclosed (made payable to Australian Education Union): $..................................................
Bankcard/Mastercard/Visa:  _ _ _ _ /_ _ _ _/ _ _ _ _ /_ _ _ _         Card
expiry date: _ _ /_ _/ _ _
Signature:
................................................... Name (please
print) ......................................................