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Membership Application/Renewal/Order
Name: ______________________________________
Address: ____________________________________
Suburb: ___________________ P/code ___________
Phone: __________________ Fax: _______________
Email: ______________________________________
$20.00 membership (student/pension)
$35.00 membership (standard)
$_______ donation
Tick the appropriate box and send a cheque or money order made payable to:
Vaccination Information South Australia
PO Box 643
Magill SA 5072