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Join AMANZ - Membership/Database form

Please print this form, complete your details, add your cheque, and send to:
Arts Medicine Aotearoa NZ
PO Box 17 215, Karori, Wellington, New Zealand
or Fax to 64 4 476 8754




I do/do not wish my details to appear on a published database form (please delete one)

This is/is not a subscription renewal. (please delete one)
Applicant's name:
Phone:
Mobile phone:
Fax:
Personal email address:
Personal postal address:
Business/Practice name:
Business email address:
Business postal address:
Business Phone:
Business mobile phone:
Business fax:
Current Occupation:
Area of arts interest:
Areas of concern
Check the box showing your membership category:
Affilate Organisations or groups - $30
Waged - $20
Unwaged - $10
Check the box which shows your interest in assisting AMANZ:
I would like to:
Attend forums/workshops/seminars
Give forums/workshops seminars
Organise workshops
Sponsor workshops
Write for an arts medicine bulletin
Distribute information through your organisation
Be placed on a database
Offer other areas - please specify
Please tick this box if you do not want your contact and practice details to appear in our next newsletter.

In accordance with Principle Three of the Privacy Act 1993,
I agree to the above information being maintained by AMANZ,
being used to circulate information and made available to like organisations

Signed: ______________________________

Date: ________________________________

Please send to:
Arts Medicine Aotearoa NZ
PO Box 17 215, Karori, Wellington, New Zealand
or Fax to 64 4 476 8754


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