Title (Mr/Ms/Dr/Prof etc):
Surname:
Given names:
School:
Position:
Mail Delivery Point:
Telephone:
Mobile:
Your email:
Date of Birth:
Gender:MaleFemalePrefer Not To Say
Home address:
Postcode:
Suburb:
Mode of Employment Teaching OnlyResearch OnlyResearch/Teaching
I hereby apply for membership of the UWA Academic Staff Association and confirm that I am employed at UWA on a casual basis. Membership is $20 per annum and commences on receipt of this fee. How to pay details will be sent on receipt of this form.
Signed:
Date
I agree the Membership Terms and Conditions
Δ
