ABN 61 170 338 903

  PRESIDENT: David Wardell B.Ed., Adv.Dip.Tchg, M.A.A.I.C.
Irlen Diagnostic Clinic
Suite 5, Pakuranga Professional Centre
267 Pakuranga Rd, Pakuranga, Auckland, NZ
Ph: +64 9 5765390

 SECRETARY: Mrs B. Freney, PO Box 733 Buderim, QLD 4556, Ph: (07) 5445 2458

 

Application for Membership

AAIC – The Australasian Association of Irlen Consultants Inc.

Category: Regional Director  Fee:AUD $66.00 NZD $74.00 (voting rights)

Text Box: Name …………………………………………………………………… Address ……………………………………………………………….. State; ……………. Postcode ………………… Country ……………. Phone: ………………………… Fax ……………………….. Email: ……………………………………………………

 

Category: Associate Members – Clinic Directors, Diagnosticians,  screeners and Pre-Assessors   Fee: AUD $33.00 NZD$37.00 (speaking rights)

Text Box: Name: ………………………………………………………………………………….. Category:(Clinic Director, Diagnostician, Screener, etc.)…………………………………………………………………… Name of Regional Director in whose area you work: …………………………………. Address: ………………………………………………………………………………... State……………. .Postcode ………. Country ………………………….. Phone: …………………………… Fax: …………………………….. Email: …………………………………………………………………

 

Category: Honorary Member. No Fees charged.  By nomination only.

 

For payment options see over page.

 

 

 

 

 

 

 

 

 

Fees: In New Zealand are payable through David Wardell, P.O. Box 39690, Howick 2145. Auckland, New Zealand for payment to AAIC Treasurer.  Please return forms and payment to David.

 

PAYMENT METHODS in New Zealand.

              Cheque, made out to Irlen Diagnostic Clinic Ltd. Post to David

                        Wardell, address above.

 

 

              Pay by Visa Card or Master Card. Fill out the slip below and post to
                        David.

_____________________________________________________________________

 

Please debit my Bankcard          Visa           Mastercard  

 

Number:             

Note:    The last three numbers are the three security numbers which are the last three on the signature strip on the back of the card.

 

Expiry Date:  ...............    Signature:..............................    

 

Name:..............................

 

Amount to be paid:  $.   

 

Thank you.

 

Peter Freney

Treasurer AAIC