Daily Membership Application Form

APPLICANT INFORMATION
Name*
Prefix First Last
Reason for Daily Membership*
- to use the car park
- to dine in the Dining Room
- to attend a meeting, seminar or conference
- to attend another type of event
- other
Please specify other reason*
Number of days that membership is required*
Please enter a number from 1 to 365.
Date required*
Day that membership is required
DD slash MM slash YYYY
Start date*
first day that membership is required
DD slash MM slash YYYY
End date*
last day that membership is required
DD slash MM slash YYYY
Additional information

Donation
From its establishment in 1911, our members and supporters have built this association through great generosity in the form of donations of funds, buildings, bequests and benefaction, together with volunteer and pro bono work. We very much appreciate your consideration of a donation, no matter how modest.
Donation amount
My donation is to be directed to:
if no selection is made, the donation will be to the highest priority and need at the time of your donation
- the highest priority and need at the time of my donation
- support residents
- the current buildings and facilities
- the capital fund for the redevelopment
Payment
Daily Membership Price
Total amount payable
$ 0.00
Payment Method*
- Debit/Credit Card
Debit/Credit Card payments are provided by ‘Stripe’, a third party payment gateway. We do not store your credit card details, or have access to them.
Credit.debit card*
Card Details
Cardholder Name
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

Your Details
Name*
Prefix First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mobile Number / Telephone Number*
Email
I wish to be named as a donor*
- Yes
- No
^ Yes' indicates that you are happy to be acknowledged (first name and surname) for your donation in our publications. 'No' indicates that you wish to remain anonymous. If neither 'Yes' nor 'No' is selected a 'Yes' response is assumed.

Payment
Total
$ 0.00
Method of Payment*
- Debit/Credit Card
- Cheque
- Bank Transfer
- Direct Debit
Bank Transfer Details
Account Name: Diamond Jubilee Campaign
Bank: ING Bank (Australia) Limited
BSB: 923 100
Account Number: 6079 1331
Swift Code: INGBAU2S
Description: Surname_Firstname_2018
- Directed to The Graduate Union of The University of Melbourne Inc.
Credit Card*
Card Details
Cardholder Name
Financial Institution*
BSB*
Account Number*
Frequency**
- Weekly
- Fortnightly
- Monthly
- Yearly
Commencing:*
DD slash MM slash YYYY
I would like to give regularly through my selected payment option*
I agree to the Automatic Payment Service Agreement
Automatic Payment Service Agreement
Signature*
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

APPLICANT INFORMATION