Queensland Academy

of Arts and Sciences

Application for election

or membership

Title: (Prof, Dr, Mr. Mrs, Miss, Ms)

Initials:

Usual First Name:

Last Name:

Postal Address:

Home Phone:

Work Phone:
Mobile:

Fax:

Email:

Employed Details:

Concession (Unwaged, Student, Retired)

Birth Date (optional): M F

Areas of particular interest:

Other Affiliations:

 

ANNUAL FEES (GST exempt – pay on invoice only)
Fellows (by nomination only): $70
Members (may apply for nomination): $50
Associates (approved by Council): $20

Each subsequent member of the same family as well as concession holders or unwaged persons are entitled to
50% off standard fee (does not apply to Associates).

You may photocopy this form for other applicants.

 

Or post to : Executive Officer
Queensland Academy of Arts and Science
P.O. Box 432, Brisbane Albert Street QLD 4002

or Fax to (07) 3210 1482

Enquiries: (07) 3210 0165 or office@qldacademy.org.au
Web: http://www.qldacademy.org.au