Individual membership application Step 1 of 3 - MEMBERSHIP DETAILS 33% This application is:* for me for another, as a gift to renew membership (individual) Individual membership - application* Individual - metropolitan Melbourne less than 60 yrs --- $150 Individual - metropolitan Melbourne ≥60 yrs --- $125 Individual - regional Victoria, interstate, international --- $125 Individual - associate --- $125 Individual - life subscription --- $1,500 Individual membership - renewal* Individual - metropolitan Melbourne less than 60 yrs --- $150 Individual - metropolitan Melbourne ≥60 yrs --- $125 Individual - regional Victoria, interstate, international --- $125 Individual - associate --- $125 This selection means that the applicant or gift recipient: - is a graduate from any university in the world - is from any academic discipline or research field - is working, in a caring role and/or (semi) retired - lives in metropolitan Melbourne - is <60 years of ageThis selection means that the applicant or gift recipient: - is a graduate from any university in the world - is from any academic discipline or research field - is working, in a caring role and/or (semi) retired - lives in metropolitan Melbourne - is ≥ 60 years of ageThis selection means that the applicant or gift recipient: - is a graduate from any university in the world - is from any academic discipline or research field - is working, in a caring role and/or (semi) retired - lives somewhere other than metropolitan Melbourne - is aged early 20s to early 100sThis selection means that the applicant or gift recipient: - has not had the opportunity to gain a degree - is from any discipline or field - is working, in a caring role and/or (semi) retired - is aged early 20s to early 100sThis selection means that the applicant or gift recipient: - is a graduate from any university in the world - seeks membership of this global collegium for life - is from any academic discipline or research field - is working, in a caring role and/or (semi)retired - is aged from early 20s to early 100s APPLICANT INFORMATIONYour name* No prefixMsMrsMissMrDrProfessorReverendAssociate ProfessorOther Title First Middle Last Post-nominals Name of person receiving this gift of membership* No prefixMsMrsMissMrDrProfessorReverendAssociate ProfessorOther Title First Middle Last Post-nominals Other*Please specifyYour date of birth:*Membership is restricted to those aged ≥18 years DD slash MM slash YYYY Do you know the gift recipient's date of birth?*Membership is restricted to those aged ≥18 years Yes No Date of birth of person receiving gift of membership DD slash MM slash YYYY Before we can grant full membership we will contact the gift recipient to gain their date of birth.Your gender* Male Female prefer not to identify Gender of person receiving this gift of membership* Male Female prefers not to identify Head and shoulders passport photograph of yourselfPlease name the photograph file to identify yourself: First Name_Last Name_Photo. The file should be less than 3MB. Once uploaded, the words 'No file selected' are replaced by the file name. If you do not have a photograph, we may contact you at a later stage to gain such.Accepted file types: jpg, png, pdf, eps, Max. file size: 3 MB.Head and shoulders passport photograph of the person receiving the gift of membershipPlease name the photograph file to identify the gift recipient: First Name_Last Name_Photo. The file should be less than 3MB. Once uploaded, the words 'No file selected' are replaced by the file name. If you do not have a photograph, we will contact the gift recipient at a later stage to gain such.Accepted file types: jpg, png, pdf, eps, Max. file size: 3 MB.Your phone number: landline or mobile*Phone number of gift recipient:*Your email address:*The tax invoice will be sent as an attachment to this email. Enter Email Confirm Email Email address of gift recipient:* Enter Email Confirm Email Your postal address:*This address is required for tax invoice purposes Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Postal address of gift recipient:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country University degree(s)University qualification(s)*List your university degree(s), adding extra rows for each degree by clicking on the circled + button. Please be advised that we undertake validation checks.Degree nameUniversityCountryYear awarded University qualification(s)*List the gift recipient's university degree(s). If you do not know their qualification details, please type in the words Not sure where applicable. For example, you may be able to indicate the university and the country but not the Degree name and Year awarded. When assessing the application, we shall contact the gift recipient to clarify and confirm these details. Please be advised that we undertake validation checks.Degree nameUniversityCountryYear awarded DONATIONFrom 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: the highest priority and need at the time of my donation support residents the current buildings and facilities the capital fund for the redevelopment If no selection is made, the donation will be to the highest priority and need at the time of your donation. I would like to donate at frequency: once-off weekly monthly annually Thank you so very much for your donation. We are truly grateful - and will be in touch soon to discuss how you would like to set up for a regular donation. Thank you so very much for your donation. We are truly most grateful. PAYMENTTotal amount payable $ 0.00 Payment Method:* Direct debit Bank transfer Debit/Credit card Debit/Credit card payments are provided by 'Stripe', a third party payment gateway. We neither store nor have access to your debit/credit card details.Bank details for transfer or direct debit Account Name: The Graduate Union of The University of Melbourne Inc. Bank: National Australia Bank BSB: 083 170 Account Number: 515612137 Swift Code: NATAAU3303M Description: Surname_Firstname_MembershipCredit/debit card*Card Details Cardholder Name I would like to pay the membership fee annually through my selected payment option* I agree to the Automatic Payment Service Agreement Automatic Payment Service Agreement I would like to pay the membership fee annually through my selected payment option* I agree to the Automatic Payment Service Agreement Automatic Payment Service Agreement CAPTCHANameThis field is for validation purposes and should be left unchanged. Application for Membership – individual Step 1 of 3 – MEMBERSHIP DETAILS 33% This application is:* for me for another, as a gift to renew membership (individual) Individual membership – application* Individual – metropolitan Melbourne less than 60 yrs — $150 Individual – metropolitan Melbourne ≥60 yrs — $125 Individual – regional Victoria, interstate, international — $125 Individual – associate — $125 Individual – life subscription — $1,500 Individual membership – renewal* Individual – metropolitan Melbourne less than 60 yrs — $150 Individual – metropolitan Melbourne ≥60 yrs — $125 Individual – regional Victoria, interstate, international — $125 Individual – associate — $125 This selection means that the applicant or gift recipient: – is a graduate from any university in the world – is from any academic discipline or research field – is working, in a caring role and/or (semi) retired – lives in metropolitan Melbourne – is <60 years of ageThis selection means that the applicant or gift recipient: – is a graduate from any university in the world – is from any academic discipline or research field – is working, in a caring role and/or (semi) retired – lives in metropolitan Melbourne – is ≥ 60 years of ageThis selection means that the applicant or gift recipient: – is a graduate from any university in the world – is from any academic discipline or research field – is working, in a caring role and/or (semi) retired – lives somewhere other than metropolitan Melbourne – is aged early 20s to early 100sThis selection means that the applicant or gift recipient: – has not had the opportunity to gain a degree – is from any discipline or field – is working, in a caring role and/or (semi) retired – is aged early 20s to early 100sThis selection means that the applicant or gift recipient: – is a graduate from any university in the world – seeks membership of this global collegium for life – is from any academic discipline or research field – is working, in a caring role and/or (semi)retired – is aged from early 20s to early 100s APPLICANT INFORMATIONYour name* No prefixMsMrsMissMrDrProfessorReverendAssociate ProfessorOther Title First Middle Last Post-nominals Name of person receiving this gift of membership* No prefixMsMrsMissMrDrProfessorReverendAssociate ProfessorOther Title First Middle Last Post-nominals Other*Please specifyYour date of birth:*Membership is restricted to those aged ≥18 years DD slash MM slash YYYY Do you know the gift recipient's date of birth?*Membership is restricted to those aged ≥18 years Yes No Date of birth of person receiving gift of membership DD slash MM slash YYYY Before we can grant full membership we will contact the gift recipient to gain their date of birth.Your gender* Male Female prefer not to identify Gender of person receiving this gift of membership* Male Female prefers not to identify Head and shoulders passport photograph of yourselfPlease name the photograph file to identify yourself: First Name_Last Name_Photo. The file should be less than 3MB. Once uploaded, the words ‘No file selected’ are replaced by the file name. If you do not have a photograph, we may contact you at a later stage to gain such.Accepted file types: jpg, png, pdf, eps, Max. file size: 3 MB.Head and shoulders passport photograph of the person receiving the gift of membershipPlease name the photograph file to identify the gift recipient: First Name_Last Name_Photo. The file should be less than 3MB. Once uploaded, the words ‘No file selected’ are replaced by the file name. If you do not have a photograph, we will contact the gift recipient at a later stage to gain such.Accepted file types: jpg, png, pdf, eps, Max. file size: 3 MB.Your phone number: landline or mobile*Phone number of gift recipient:*Your email address:*The tax invoice will be sent as an attachment to this email. Enter Email Confirm Email Email address of gift recipient:* Enter Email Confirm Email Your postal address:*This address is required for tax invoice purposes Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Postal address of gift recipient:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country University degree(s)University qualification(s)*List your university degree(s), adding extra rows for each degree by clicking on the circled + button. Please be advised that we undertake validation checks.Degree nameUniversityCountryYear awarded University qualification(s)*List the gift recipient’s university degree(s). If you do not know their qualification details, please type in the words Not sure where applicable. For example, you may be able to indicate the university and the country but not the Degree name and Year awarded. When assessing the application, we shall contact the gift recipient to clarify and confirm these details. Please be advised that we undertake validation checks.Degree nameUniversityCountryYear awarded DONATIONFrom 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: the highest priority and need at the time of my donation support residents the current buildings and facilities the capital fund for the redevelopment If no selection is made, the donation will be to the highest priority and need at the time of your donation. I would like to donate at frequency: once-off weekly monthly annually Thank you so very much for your donation. We are truly grateful – and will be in touch soon to discuss how you would like to set up for a regular donation. Thank you so very much for your donation. We are truly most grateful. PAYMENTTotal amount payable $ 0.00 Payment Method:* Direct debit Bank transfer Debit/Credit card Debit/Credit card payments are provided by ‘Stripe’, a third party payment gateway. We neither store nor have access to your debit/credit card details.Bank details for transfer or direct debit Account Name: The Graduate Union of The University of Melbourne Inc. Bank: National Australia Bank BSB: 083 170 Account Number: 515612137 Swift Code: NATAAU3303M Description: Surname_Firstname_MembershipCredit/debit card*Card Details Cardholder Name I would like to pay the membership fee annually through my selected payment option* I agree to the Automatic Payment Service Agreement Automatic Payment Service Agreement I would like to pay the membership fee annually through my selected payment option* I agree to the Automatic Payment Service Agreement Automatic Payment Service Agreement CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
