RENEWAL FORM
INDIVIDUALS
Please send completed form to:
ICOM Australia
PO Box 266
CIVIC SQUARE ACT 2608
e-mail: [email protected]
or
Louise Douglas (Membership Secretary)
e-mail: [email protected]
ABN 47 613 685 234
2010
2017
Renewal of individual membership
Regular and Retired Individual Members of ICOM are invited to renew their Membership for 2017. Memberships ‘lapse’
if not renewed by 31 March 2017.
Former members may renew without penalty, but must advise of any changes in professional status or contact details.
All renewing members must certify that they are not dealing in cultural property.
Last name:
Title:
Given names:
Mr

Mrs

Ms

Prof

Dr

ICOM membership number:
Your institutional (or former) position:
Your institution’s (or former) name:
Institution’s postal address:
Suburb:
State:
Post code:
Tel:
(please include area code)
Fax:
(please include area code)
Mobile:
E-mail:
Institution’s web address:
Postal address (if different from above):
Suburb:
State:
Post code:
Private tel:
Private fax:
(please include area code)
(please include area code)
Private mobile:
Private e-mail:
Are you a member
of Museums
Australia?
MA1 individual members are entitled to 5% discount on ICOM Australia membership
Yes

MA membership no.:
_________________
Preferred method of receiving ICOM Australia
correspondence:
1
Museums Australia
Version 1.0, 2017
E-mail 
No

Post

PTO

Do you wish to receive e-bulletins?
Membership
category:
Method of payment:
EFT (uses
Museums Australia
account)
Make cheques/
money orders
payable to ICOM
Australia
Yes

No
Regular professional
$ 154.00 / MA member
$146.30
Retired professional
$ 72.00 / MA member
$ 68.40
Electronic funds transfer

Cheque/ 
money order



Credit card 
(Visa/MasterCard only)
BSB: 062—900
Account No: 10216161
Please use the note field to give your name and mark ICOM renewal
Payable to:
ICOM Australia
Send to:
ICOM Australia PO Box 266, CIVIC SQUARE ACT 2608
Credit card details
Type:
Visa

MasterCard

Name on card:
Credit card no.:
Expiry date:


Regular professional
$ 154.00 / MA member $146.30 $____________
Retired professional
$ 72.00 / MA member
Amount:
$ 68.40 $____________
Donation $____________
TOTAL $
Signature:
Membership period
Membership is annual from 1 January – 31 December.
Privacy
ICOM Australia sets out in its Privacy Statement how it collects, uses and discloses members' personal information.
This statement is framed by the Privacy Act 1988 (Cth) and as amended. The Privacy Statement can be found at:
www.icom.org.au/policiesprivacy.php
Information you provide on this form will be transmitted to third parties: ICOM headquarters and ICOM’s International
Committees. You have the right to access and to modify your information. The French law on Informatics & Civil
Liberties (Jan. 6, 1978, rev.) provides for the equivalent right.
Authorisations
I authorise ICOM including ICOM Australia to publish my information
on their websites (access to this information is restricted to ICOM
Australia officers, ICOM Paris officers, ICOM committees, ICOM
affiliated organisations & member services providers)
I authorise ICOM including ICOM Australia to transmit my
information to non-ICOM third parties (such as conference organisers,
Museums Australia, printers, mail distributors etc)

professional information 
private information

professional information 
private information
Declaration
I, _______________________________, hereby declare that I remain eligible for membership and I
formally
accept
and
respect
the
ICOM
Code
of
Ethics
for
Museums
(http://icom.museum/ethics.html). I am not engaged in dealing (i.e. buying and selling for profit)
cultural goods including works of art or natural and scientific specimens.
Date:
Signature:
Version 1.0, 2017