Membership Renewal 4 August 2016 Tweet [Membership] Membership Renewal 2016-2017 Please use this form to renew your Alliance Membership for 2016-2017. If you have any questions about your membership please contact email@example.com for assistance. Not already a member? Click here for information about becoming a member of the Alliance Please Select*Please SelectI am an individual who holds a confirmed membership with the AllianceWe are a not-for-profit organisation whose work is primarily with L, G, B, T, or I people (>85% of our budget)We are an organisation whose work is broader than LGBTI Health but who work to support these communities/populationsHave you previously been approved as an Alliance Member?*Please selectYesNoNew Membership Applications Please visit www.lgbtihealth.org.au/membership for information about becoming a Member of the LGBTI Health Alliance. Full Membership Renewals Corporate Membership Renewals Individual Membership Renewals Contact Details Please enter the name and contact details for the person who will be responsible for maintaining this Alliance Membership during 2016-2017.Name* First Last Email* Organisations Name*Postal Address* Street Address Address Line 2 City State / Province / Region 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 Not-for-profit Status*Please selectNot-for-profitFor-profitAnnual Operating Budget*Less than $500,000Between $500,000 - $1mGreater than $1mThis is used to calculate your organisations membership fee.ABN*State/Territory of Incorporation or residence*Please selectACTQLDNSWNTSATASVICWAInternationalWebsite* http:// required at the beginning of your address. Please indicate your affirmation of the following Alliance principles*All four items are required for Membership. 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 PaymentRenewal is confirmed upon payment of your membership fee.Payment Method*Credit Card/ PaypalRequest InvoiceCorporate Membersihp Fee (For-profit)* Price: $ 1,000.00 Corporate Membership Fee (Not-for-profit)* Price: $ 300.00 Individual Membership Fee* Price: $ 25.00 Full Member < $500,000* Price: $ 75.00 Full Member between $500,000 - $1m* Price: $ 250.00 Full Member greater than $1m* Price: $ 750.00 Total $ 0.00 PhoneThis field is for validation purposes and should be left unchanged.