Dr
  Mr
  Mrs
  Miss
  Ms
  Other Title

  Given Name**

  Surname**

  Organisation**

  Position**

  Mailing Address**
(PO Box or Street No and Name)

  City/Suburb**

  State

  Postcode**

  Country

  Your E-Mail Address**

  Contact Phone
(include country & area codes)

  Contact Fax
(include country & area codes)

Comments:

I wish to apply for free membership of the ICTC Society and will allow the above details to be entered into the ICTC Society data base for the sole use of the Society to forward information regarding the Society and its activities.

Your membership can also be registered by printing out this form and mailing or faxing to:

ICTC Society
PO Box 1380
Palm Beach, Queensland 4221
AUSTRALIA
Phone: +61 7 55 204 288
Fax: +61 7 55 082 175