Concessional membership renewal form To renew your membership, please fill out the form below. Section A - Personal informationName* Mr.Mrs.MissMs. Title First Last Email Membership IDThis field is optionalHave your contact details changed?*NoYesIf yes, please enter your new contact details below.Section B - Types of membership and feesMembership types*Concessional member ($10/year) Annual membership is renewable by 30 June each year. *Concession rates are available to anyone who is in receipt of a Commonwealth Government pension card.Section C - DonationWould you like to make a donation today?*YesNoDonation amount*How much would you like to donate? Section D - PaymentMethod of payment*VisaMasterCardTotal due $ 0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name Section E - Consent for collection, use and disclosurePersonal and Health Information – Privacy Notice Personal information collected on this form will be retained and used for the purpose of processing and delivering Spinal Life Australia Ltd membership applications for services, programs and normal business practices. It may also be used for other purposes including keeping you informed about the organisation’s activities, events, member networks, distributing publications and providing you with information about things we think may be of interest to you. Without this information we may be unable to provide the member services and programs as intended. De-identified personal and health information may be used for research and statistical purposes for planning services by the organisation or distributed to third parties, such as government agencies or other agencies with an interest in the research. Be assured that this type of data is always de-identified. Personal information will not be disclosed to third parties without consent or in accordance with the law. We take steps to protect all personal, sensitive and health information held against misuse, interference, loss, unauthorised access, modification and disclosure. Credit card details are not stored. You can access the personal information that we hold about you, and you can ask us to correct the personal information we hold about you. If you are listed on one or more of our network email lists you can opt out at any time. You can unsubscribe by using the ‘unsubscribe’ options noted in our emails. How to contact us Individuals can obtain further information or provide any comments in relation to this privacy notice, by accessing the Privacy and Confidentiality Policy through our website, or contacting Spinal Life Australia: Website – Contact us or Leave feedback Privacy Officer – firstname.lastname@example.org Address - 109 Logan Rd, WOOLLOONGABBA QLD 4102. PO BOX 5651 WEST END QLD 4101. Ph: 07 3391 2044, Fax: 07 3391 2088, Freecall: 1300 774 625, member enquiries email@example.com.