Renewal of Postgraduate Student Membership

ABN 47 613 685 234 /

RENEWAL FORM

POSTGRADUATE STUDENT
Please sendcompleted form to:

ICOM Australia

PO Box 266
CIVIC SQUARE ACT 2608
e-mail:
or
Louise Douglas (Membership Secretary)
e-mail:

Renewal of postgraduate student membership

Postgraduate Student Members of ICOM are invited to renew their Membership for 2017. Memberships ‘lapse’ if not renewed by31 March2017.

Former members may renew without penalty, but must advise of any changes in professional status or contact details. All renewing members must certify that they are not dealing in cultural property.

Last name: / Given names:
Title:Mr Mrs Ms Prof Dr
ICOM membership number:
Postgraduate course of study: / Expected year of completion:
Your institution’s name:
Institution’s web address:
Private postal address(if different from above):
Suburb: / State: / Post code:
Private tel:
(please include area code) / Private fax:
(please include area code)
Private mobile: / Private e-mail:
Supporting material: / Renewing postgraduate student members must enclose evidence of their educational institutional affiliation and course details. For example: current Record of Enrolment or letter from the institution’smuseum related school/department. A student ID card IS NOT acceptable.
Type of material enclosed:
Preferred method of receiving ICOM Australia correspondence: / E-mailPost
Do you wish to receive e-bulletins? / YesNo

Membership category: / Postgraduate student$ 62.00
Method of payment: / Electronic funds transfer  Cheque/ Credit card 
money order (Visa/MasterCard only)
EFT (uses Museums Australia account) / BSB: 062—900Account No: 10216161
Please use the note field to give your nameand mark ICOM renewal
Make cheques/ money orders payable to ICOM Australia / Payable to:ICOM Australia
Send to:ICOM Australia PO Box 266, CIVIC SQUARE ACT 2608

Credit card details

Type: / VisaMasterCard
Name on card:
Credit card no.:
Expiry date:
Amount: / Postgraduate student$ 62.00$______
Donation$______
TOTAL$
Signature:

Membership period

Membership is annual from 1 January – 31 December.

Privacy

ICOM Australia sets out in its Privacy Statement how it collects, uses and discloses members' personal information. This statement is framed by the Privacy Act 1988(Cth)and as amended. The Privacy Statement can be found at:

Information you provide on this form will be transmitted to third parties: ICOM headquarters and ICOM’s International Committees. You have the right to access and to modify your information. The French law on Informatics & Civil Liberties (Jan. 6, 1978, rev.) provides for the equivalent right.

Authorisations

I authorise ICOM including ICOM Australia to publish my information on their websites (accessto this information is restricted to ICOM Australia officers, ICOM Paris officers, ICOM committees, ICOM affiliated organisations member services providers) / private information
professional information
I authorise ICOM including ICOM Australia to transmit my information to non-ICOM third parties(such as conference organisers, Museums Australia, printers, mail distributors etc) / private information 
professional information 
Declaration
I, ______, hereby declare that I remain eligible for postgraduate student membership and I formally accept and respect the ICOM Code of Ethics for Museums ( I am not engaged in dealing (i.e. buying and selling for profit) cultural goods including works of art or natural and scientific specimens.
Date: / Signature:

Version 1.0, 2017