ABN 47 613 685 234 /

RENEWAL FORM

SUPPORTING INDIVIDUAL

Please send completed form to:

ICOM Australia

PO Box 266
CIVIC SQUARE ACT 2608
e-mail:
or
Louise Douglas (Membership Secretary)
e-mail:
Renewal of supporting individual membership
Supporting Individual Members of ICOM are invited to renew their Membership for 2017. Memberships ‘lapse’ if not renewed by 31March2017.
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.
Supporting Membership is available to individuals or institutions who are providing substantial financial or other assistance to ICOM because of an interest in museums and international co-operation between museums. Such individuals or institutions are not eligible for regular individual or institutional membership.
Supporting Members, like regular ICOM members:
  • must not deal (buy or sell for profit) in cultural materials of any kind
  • have no conflicts of interest with ICOM's Mission and Purpose.
  • accept ICOM's Code of Ethics for Museums.
Current supporting individual members may renew:
  • by cheque or money order, made payable to ICOM Australia, along with this form
  • by credit card (Visa or MasterCard only), along with this form

Last name: / Given names:
Title:Mr Mrs Ms Prof Dr
ICOM membership number:
Postal address:
Suburb: / State: / Post code:
Tel:
(please include area code) / Mobile:
E-mail: / Web address:
Are you a member of Museums Australia? / MA[1] individual members are entitled to 5% discounton ICOM Australia membership
YesMA membership no.: ______No
Preferred method of receiving ICOM Australia correspondence: / E-mail Post 
Do you wish to receive e-bulletins? / Yes No 
2017 membership subscription: / Supporting membership (full)$ 440.00 
Supporting membership (MA member)$ 418.00 
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: / Supporting membership (full) $440.00 $______
Supporting membership (MA member) $ 418.00$______
Donation$______
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 (access to 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 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

[1] Museums Australia