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Membership Change Form

Member Details

First Name*

Last Name*

Email*

Mobile*

New Membership Type*

New Membership Start*

Company Name

First Name

Last Name

Email

Mobile

Remarks

Confirmation

The highlighted checkbox*

I confirm that the information provided in this form is complete, true and correct to the best of my knowledge

The highlighted checkbox*

I confirm that I have been briefed on any applicable charges and impacts related to the membership change requested

The highlighted checkbox*

I acknowledge and agree by typing my name below that this form of electronic signature has the same legal force and effect as a manual signature

Print Name*

Office Use Only

Employee Name*

Employee ID*

Checklist

Checkbox 1*

I have briefed the member on applicable fees and charges related to the membership change requested

Checklist 2*

All relevant documents have been sighted and verified for the membership change requested