Membership Form

Fields marked * are mandatory.

Are you applying as a company or an individual? Company Individual

Company name /
Surname (for individuals) *

First name

For individuals only

Title (individuals only)

For individuals only

Trading as

A.B.N.

For companies only

Business description

For companies only

Location details

Postal address *

City / Suburb *

State *

Postal code *

Country

Reception phone

Fax

General Email *

Website

Contact details

Surname *

First name *

Title *

Email *

Telephone number

Mobile number

Fax

Membership details

Membership type *

Turnover in sales for last financial year (AUD$)

Supplier only

Turnover in weekly sales (AUD$)

Retailer only

Number of members

Affiliate associations only

Publish name & website details on CHC website?

Declaration

I / We hereby declare that that the above information is true and correct *

I / We hereby declare that I / We have read and agree to abide by the CHC's Code of Practice for the Marketing of Complementary Healthcare and Healthfood Products. *