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Organisational Membership Form

The Organisation named below hereby applies for Membership of the SNHN Ltd (Sydney North Health Network) pursuant to clause 5 of the constitution1.

Organisation

The organisation's aims/objectives are compatible with the objects of SNHN and we agree to be bound by the constitution governing SNHN.

Organisation:
ACN:
ABN:
Postal Address:
Street Address:
Registered Address:
Website:
Phone number:
Fax number:
SNHN staff member that referred you:

Nominated Organisational Representative

Each organisation must nominate a Representative. The Corporate Representative will receive correspondence from the Company and will have power to vote on behalf of the organisation.

Full name:
Role:
Postal Address:
Phone Number:
Fax Number:
Mobile Number:
Email Address:
Membership Eligibility

Please outline the nature of the business your organisation undertakes in relation to primary health care in the Sydney North region:

Nature of business:
Please summarise your interest in the provision of primary health care in the Sydney North region:

Please indicate which requirement your organisation meets:
Is a Peak body: Is a peak body;
Is a Service Provider: Is a service provider;
Is an organisation that represents the community or consumers in the area, and has demonstrated leadership and capacity in integrative health care delivery in the area: Is an organisation that represents the community or consumers in the area, and has demonstrated leadership and capacity in integrative health care delivery in the area;
Applicant Consent:
I have read the Consent Declaration below: I have read the Consent Declaration below.
As a member of Sydney North Health Network, I agree to accept and abide by the terms and conditions of the Company Constitution1: As a member of Sydney North Health Network, I agree to accept and abide by the terms and conditions of the Company Constitution.
Consent Declaration:

Sydney North Health Network collects personal information about members, necessary for managing the work of the Company and related programs. Such personal details will be handled by the Company staff in accordance with the Privacy and Confidentiality Procedure and Commonwealth and State privacy laws – Commonwealth Privacy Act (1988) www.privacy.gov.au.


1SNPHN Ltd Constitution is available on the SNHN website.

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