Membership and Donation

Complete the form below to join, renew &/or donate.

1. About You

Title
Your First Name
Your Last Name
For Couples Membership
Your Email
Street/PO Box
Suburb
PostCode
State/Territory
Phone
Year of Birth (optional)

2. Type of membership

Type of Membership

*concession rates apply to means-tested pensioners
Are you
Renewing your membershipA New memberMaking a donation

3. Payment Method

Select your payment method
Direct Bank TransferCheque
Date of Bank Transfer

Direct Bank Transfer details:
BSB 325 185 Account 03415176 Dying With Dignity ACT
Please include your name in the reference field so we know who has made the payment
Cheques to:
PO Box 55
Waramanga ACT 2611

4. Lodge your completed form

Need a paper based form?

Click here to download a paper form.

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