Membership Applications [Membership] Membership Applications Please use this form to apply for Membership with the National LGBTI Health Alliance. Membership Category*Please select the category of membership for which you would like to apply. For a full description of these categories, please visit: www.lgbtihealth.org.au/membershipFull MembershipCorporate MembershipIndividual MembershipNot-for-profit Status*Please selectNot-for-profit OrganisationFor-profit OrganisationPlease note that Full Membership is only available for Not-For-Profit organisations. Full details of our membership structure are available at www.lgbtihealth.org.au/membershipContact DetailsFor organisations: These are the details of the person in your organisation who will be responsible for maintaining this membership. Pronouns* He/Him/His She/Her/Hers They/Them/Theirs None/My Name My pronouns are... What are your pronouns?Name* First Last Email* Enter Email Confirm Email Location* City State or Territory ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country About your organisationName of Organisation*A.B.N*Generic Email Contact*An account that does not change with staffing changes. Website* Postal Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code State/Territory of Incorporation or Residence*The place where your organisation was incorporated, or where you reside as an Individual Member.ACTQLDNSWNTSATASVICWAInternationalDescription of core business*Supporting Documentation [PDF]*Please provide documentation that demonstrates your support for our Guiding Principles. This might include your organisations constitution, a policy statement, or examples of projects, etc. If you are unsure, please contact our membership officer at firstname.lastname@example.org [Max 10MB]Accepted file types: pdf.Secondary ContactsAs a Member of the Alliance, staff from within your organisation are able to access our Member resources and forums. Please use this space to list the names and email addresses of anyone you might like to have included. You can always add/remove addresses later.About youThese questions are optional. This is a space we hope you will feel inspired to share with us some details about your body, gender, or relationships. This information is private and confidential. Gender Experience / Identities Agender/Nongendered Female Genderqueer Male Non-binary Unsure/Questioning Not specified I would like to use another term How would you describe your gender identity or experiences?IntersexIntersex is a term for people born with physical sex characteristics that differ from modern medical norms about ‘female’ and ‘male’ bodies. These characteristics may be apparent at birth or may manifest during physical development. Do you have an intersex variation?Please selectYesNoTrans Experience and/or IdentityTrans and Transgender are umbrella terms often used to describe people who were assigned a sex at birth that they do not feel reflects how they understand their gender identity, expression, or behaviour. Do you consider yourself to have a trans or transgender experience and/or identity? Please selectYesNoSexualitiesHow would you described your sexuality? Your workOccupation / RolesReason for this application*Please take a moment to describe your motivations and hopes for joining the Alliance. Legal DeclarationPlease indicate your affirmation of the following Alliance principles*All four items are required for Membership. Read the guiding principles. I/we affirm the guiding principles of the LGBTI Health Alliance. I/we confirm that I have received a copy of the Constitution of the National LGBTI Health Alliance I/we consent to be a member of the National LGBTI Health Alliance and agree to be bound by its constitution and code of conduct I/we agree to the guarantee amount of $25 in event of a winding up in accordance with clauses 2.2 and 19 of the Constitution PaymentPayment of the membership fee is required for consideration of this application. In the rare circumstances that membership is not possible at this time a refund will be issued.Payment Method*Credit Card/Paypal (Default)Request Invoice$300.00$1000.00Fee Scale for Full Members: Less than $500,000 = $75 Between $500,000-1m = $250 Greater than $1m = $750Operating Budget*This information is used to calculate your membership fee.Less than $500,000Between $500,000 - $1mGreater than $1mFull Member Fee 1* Price: $ 75.00 Full Member Fee 2* Price: $ 250.00 Full Member Fee 3* Price: $ 750.00 NFP Membership Fee* Price: $ 300.00 FP Membership Fee* Price: $ 1,000.00 Individual Membership Fee* Price: $ 25.00 Total $ 0.00 Coupon PhoneThis field is for validation purposes and should be left unchanged.