GEMA MEMBERSHIP APPLICATION     ABN: 85 325 860 032

Please print, complete and mail with payment to:

Government Entities Marketing Association

64 Grenadier Drive

Thornlie WA 6108

Ph: (08) 9459 8465

Fax: (08) 9459 8465

Mobile: 0411 088055

Mr / Mrs / Ms / Miss Surname

Given Name ...........................................................

Company Name ......................................................

Position ................................................................

Job Description ......................................................

Business Address ...................................................

...........................................................................

Postcode ................................. Telephone .........................

Fax ........................................ Email ...................................

Signature ................................. Date ................................

Type of Membership: Please tick

Sponsor: $1500

Member or Corporate Member: $150-1  $250-2  $345-3  $420-4

Service Provider Member: $150

Method of Payment: Please tick.

Cheque Purchase order Credit Card

Please charge my M / Card, Visa, Diners, Bankcard, Amex

No .........................................Expiry Date ................................

Cardholder Name .....................................Cardholder Signature ..........................................