Australia New Zealand Marine Biotechnology Society Inc.

for the advancement of marine biotechnology

Membership application

Please double-click check boxes to select options if filling in this form electronically.

Title:
First Name:	Middle Initial:
Last Name:
Institution / business name: Institution / business address: (Check this box to use your institution as your mailing address)
Residential Address (optional): Australia New Zealand Other Country Please state: (Check this box to use this as your mailing address)
Email:
Research areas of interests:
Phone: (Please include country and area codes)
Mobile phone: (Please include country code eg. +61)
Annual Subscription Rates (until – 30/6/17)
Membership Type	Subscription (1 year)	Subscription (2 years)	Subscription (3 years)
Professional (current or retired)	$ 30	$ 60	$ 90
Student	$ 20	$ 40	$ 60
Associate (non-voting)	$ 35	$ 70	$ 105
Corporate *	$150	$300	$450

* Corporate - The person named on this sheet will be the main corporate contact. Please provide names and email addresses of additional members on a separate sheet. If more than 6 people add $25/person.

RULES: By becoming a member of the Society you agree to abide by the rules. A copy can be found at http://www.flinders.edu.au/medicine/sites/marine-bioproducts/network/marine-biotech-network.cfm

DONATION/SPONSORSHIP: Please contact the treasurer if you would like to provide a further donation to the society marine.bioproducts@flinders.edu.au.

Corporate Membership additional members (attach extra lines for additional members)

Title	First name	Second name	Email address	Student?
2	Select
3	Select
4	Select
5	Select
6	Select

(If students are included in corporate membership the rate is the same as Professionals)

Payment Method ,
EITHER Electronic Funds Transfer (EFT) payments should be made to: If you live in Australia Account Name: Australia-New Zealand Marine BSB: 805-050 (People’s Choice CU) Account No: 100175050 If you live in New Zealand Account Name: ANZMBS Account Number: 06-0433-0525275-00 (ANZ bank) To assist with identifying your EFT payment, please use your name as the message when entering the transfer information. If you have the facility, please use the ‘email this transaction’ option to marine.bioproducts@flinders.edu.au
OR Cheque or Money Order should be made payable to the Australia New Zealand Marine Biotechnology Society (ANZMBS). Please cross the cheque and write your details on the back. Postal address: In Australia Treasurer, Australia New Zealand Marine Biotechnology Society, c/o Centre for Marine Bioproducts Development. HLTH 4.17 Dept. of Medical Biotechnology, Flinders University; GPO Box 2100, Adelaide, South Australia, Australia 5001 In New Zealand Prof. Chris Battershill, Gate 1, Knighton Road, Private Bag 3105, Hamilton, New Zealand
If your institute is paying for your membership My institute requires an invoice To be sent to: Name Address

Please forward completed form to marine.bioproducts@flinders.edu.au

Any additional banking transaction fees should be paid for by the payee / sender.

Membership will commence on successful receipt of annual subscription funds and processing of application form.