Annual Administration/ Access Fee

For financial year 1 July 2017 to 30 June 2018

The annual Administration/ Access Fee is due and payable by the 1st July 2017

FULL MEMBER (no Concession card) - $60
PENSIONER/ HEALTH CARD HOLDER (proof required) - $50
(If claiming a concession benefit, a photocopy of your Pension/ Health card MUST be forwarded to IA Vic office)

Unfinancial members are not able to receive ostomy supplies until this fee is paid.
- The Treasurer

General Info

Title  Mr Mrs Ms Miss First Name
Surname

Contact Details

Preferred Contact Number
   
Email Address
 

Residential/ Postal Address

Unit/ Street No.
Street
Suburb
State
Post Code
 

Membership Info (If Known)

Membership Number
   
Medicare No
Expiry
 
Pensioner/ Health Card No
Expiry
 

Payment Info

Preferred Payment Method

 Direct Deposit Cash Credit Card Cheque Money Order

Cheques and Money Orders made payable to
ILEOSTOMY ASSOCIATION (VIC) INC.

Mailing Address:
PO BOX 32,
Flinders Lane, 8009
Direct Deposit Info:
Commonwealth Bank
Account Name: Ileostomy Association (Vic) Inc.
BSB: 063 010
Account No.: 11382779
Amount Paid:

Date Paid:
Please note: Please identify your payment with your name or membership number and a word describing the payment ie. Fees

Paying by Credit Card:
We cannot currently process credit card payments through the website. If you would like to pay via credit card, please call us on

(03) 9650 9040 (during office open hours)
     
Signed by patient, parent, guardian or carer (fill in name)
Date