IBIS MEMBERSHIP APPLICATION
POST TO IBIS PO BOX 4853 FOREST LAKE QLD 4074 (PH 07 3372 2091)
OR COPY AND EMAIL TO contact@ibis-australia.org
Circle MR MRS MISS MS DR
PLEASE PRINT
Family Name................................................................................
First Name....................................................................................
Date of birth ................./............../.....................
Occupation...................................................................................
Address.......................................................................................................................
Suburb........................................................................................................................
State.................................................................Postcode...........................................
Phone (
)..............................................................
Mobile................................................................................................
Email..........................................................................................................................
Circle IBS Type A A+ B C C+ D D+
Signature..............................................................
Joining Fee
Annual Subscription
Pensioner Discount ($3)
Donation
Total
$10
+$25
$_____
=_____
A alternating between
diarrhoea and constipation
A+ alternating plus
pain/bloating
B pain and/or bloating
C constipation predominant
C+ constipation plus
pain/bloating
D diarrhoea predominant
D+ diarrhoea plus
pain/bloating
Cheque/Money Order ______
Card Number
Expiry Date............./................
Name on Card.............................................................................
Signature.....................................................................................
Annual subscriptions are due 1 April each year
Donations $2 and over are claimable as an Income Tax Deduction
Member No...................................
Receipt No...................................