Update your member contact details

Position

1. Please provide the following details for your organisation.

Organisation Name

Street Address (Line 1)

Street Address (Line 2)

Town or Suburb

Postcode

Postal Address (Line 1)

Postal Address (Line 2)

Town or Suburb

Postcode

Phone

Email Address

Fax

Preferred method of contact

Phone

Post

Fax

2. Please provide the following details for the organisation's Chief Executive Officer (or equivalent)

Position

Title (e.g. Dr, Mr, Mrs)

Full Name

Phone (Work)

Phone (Mobile)

Email Address

Executive Assistant Name

Email Address

3. Please provide details of a nominated Board authorised delegated representative who will be primarily responsible for Governance responsibilities and having voting rights at the CheckUP AGM

Position

Title (e.g. Dr, Mr, Mrs)

Full Name

Email Address

4. Please provide details of the individual who will be primarily responsible for Finance (e.g. membership renewal and event registration payments)

Position

Title (e.g. Dr, Mr, Mrs)

Full Name

Email Address

5. Please provide the following details for the membership contact person you wish to receive all correspondence relating to your CheckUP membership.

Position

Title

Name

Phone (work)

Preferred method of contact

6. Please provide details of any other staff members you would like recorded in our database and to receive our eNews

Position

Full Name

Email Address

Full Name

Email Address

Full Name

Email Address

If you have more than 3 additional staff to add to our database please provide their details in an email or spreadsheet to membership@checkup.org.au

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