HAPIA - The Health and Productivity Institute of Australia

Membership Form

* Required

First Name *	Last Name *
Email Address *
Name of Organisation *	ABN:
Name of nominated representative: *
Type of Membership * Provider Membership 2011/12 ($1,650 inc GST)
Note: Provider Members must be actively involved in the delivery of employee health and wellness services to Australian/NZ companies. This may involve online or other mechanisms and may encompass both physical and/or psychological wellbeing.
Mailing Address
Street *	City *
State *	Postcode *
Phone	Fax
Do you wish your logo to appear on the HAPIA website with hyperlink to your URL? Yes No
Attach File (100Mb Limit *) If yes, please provide image or your company logo for inclusion on the HAPIA website. This will be used to provide a hyperlink directly to your company’s home page
Payment Method * Cheque: Payable to HAPIA (1305/77 Berry St North Sydney NSW 2060) Online Deposit - Account #032007 366626 (Westpac)
Enter Word Verification in box below *