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New Member       Diabetes Australia - Queensland General Membership Application Form Personal Details Title: First Name: Surname: Your Address Address 1: Address 2: Suburb or Town: State: Please Select ACT NSW NT QLD SA TAS VIC WA Postcode: Work Phone: Home Phone: Mobile: Fax: Email: Occupation: Date of Birth: For Applicants under 18 please provide name of Trustee (Parent or Guardian) Title: First Name: Surname: I am joining Diabetes Australia - Queensland because I have: (please tick one option only) Pre-diabetes Type 1 diabetes Type 2 diabetes controlled by diet & exercise Type 2 diabetes and require tablets Type 2 diabetes and require insulin Gestational Diabetes (diabetes in pregnancy) I do not have Diabetes How did you first find out about DAQ? Doctor Diabetes Educator Nurse, Dietitian, Optometrist Friend/Relative Pharmacy DAQ Awareness/Advertising What are you main reasons for becoming a DAQ member? Magazines / Newsletter Discounted Products Voice for people with diabetes - Advocacy Diabetes Information To support diabetes research Do you experience difficulty in either of the following? (please tick) Maintaining regular exercise Managing your diet Do you have any special interests? Annual Membership Fee Please tick the appropriate fee. Please select the appropriate 'Full' or 'Pensioner' membership type: Full DAQ membership ($55.00 AUD) Pensioner membership ($29.00 AUD) Cost: $ ..or enter your specified amount here. Pensioner membership applies to full pension only. Please enter your pension number I wish to make a donation to help people with diabetes. Enter Amount: $ AUD Total Amount: $ AUD Desired Method of Payment Cheque or money order (made payable to Diabetes Australia - Queensland) can only be accepted by post. You will need to print out your order form by clicking the print button at the bottom of this page and post with payment to Diabetes Australia - Queensland. Secure Credit Card You will be directed to a secure form to fill in credit card details. Create a Member Login Upon submission of this application form, you will automatically receive notification via email of a Temporary Member Login and Password enabling you to gain immediate access to all the benefits of DAQ membership. Your Rights: you neet not give us any of the personal information requested by us. However, without this information, we may not be able to provide the level of service you require. Join our e-newsletter DAQ's members only e-newsletter will keep you up to date on new diabetes management informtaion, products and events posted on the DAQ site. I wish to receive the DAQ e-newsletter Confirm your application To receive your temporary membership number and password, you will need to submit your application now. If you are paying by money order or cheque please print your application form after confirming your application. Your receipt and DAQ membership card will be mailed to you.

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