Forms – Form design Bruce Jones 2007 Workplace Trainer & Assessor – delivering practical quality solutions
ACIA Membership Application Form
Name
©ACIA 
Address
Home
Work
Telephone
Email/s
Yes
Are you an ACIA qualified guide?
No
Level
Are you applying for associate or full membership?
Has your membership lapsed for more than 2 years? If so, you will need to pay a fee (below) and fill in
the lapsed membership log to attach to this form
Are you maintaining your qualification from last year?
If so, have you maintained the currency requirements for your qualification?
In applying for membership in the ACIA I am agreeing with the aims and objectives of the association. All of the
information provided and statements and claims made are true to the best of my knowledge.
Direct Deposit
Credit card
Cheque
Cash
BSB 633-000
A/c no. 124580085
Payment
method
Membership will be valid for the remainder of the calendar year.( $85.00 for full membership for one year or $160
for two years)
Associate memberships costs $25/year and are available to clubs, gyms, schools, etc., and interested individuals who
do not wish to be registered guides or who are not yet qualified, but want to support the ACIA and its mission.
Lapsed membership of more than 2 years incurs an application fee of $25.
Card Type
Exp Date
Card No.
Name on card
Credit use incurs a 4%
bank charge
___/___
Additionally, until this authority is revoked by me, I
authorize the ACIA to charge my credit card $85
annually for my membership renewal, plus 4% credit
card charge.
Date:
Yes
No
Signature:
Forms – Form design Bruce Jones 2007 Workplace Trainer & Assessor – delivering practical quality solutions