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| Please post to IBIS - Australia, IBIS PO Box 461 MT OMMANEY QLD 4074 |
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Date : ____/____/____ |
| Title - Mr / Mrs / Ms / Miss / Dr / Sr . Please circle correct title. |
| Surname : __________________________________________ |
Birth Date : ____/____/____ |
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| Given Names : ______________________________________ |
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| HOW DO YOU LIKE TO BE ADDRESSED? (Given Name etc): __________________________ |
Address : __________________________________________
__________________________________________________ |
Postcode : _________ |
Type of IBS 
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A = Alternating between Diarrohea and Constipation
A+ = Alternating plus pain and / or bloating
B = Pain and or Bloating predominant
C = Constipation predominant
C+ = Constipation and Pain and or Bloating
D = Diarrohea predominant D+ = Diarrohea and Pain and or Bloating and
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| Telephone No. : Home : (___)_________________ Work : (___)_________________ |
| Signature : _______________________________ |
Joining Fee : |
$ 10.00 |
| Occupation/Previous Occupation : ______________________ |
+Membership : |
$ 25.00 |
| Discount for Social Security Beneficiaries of $3.00- |
Sub-Total : |
$ 35.00 |
| Please quote your pension number : _____________________ |
Pen. Discount : |
__________ |
| Donations of $2 or more may be claimed as an income tax deduction |
+Donation Please : |
__________ |
| Bankcard / Mastercard / Visa (Please underline type) |
TOTAL : |
__________ |
Card Number :
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Cardholder Name : __________________________
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Signature :
______________________ |
Expiry Date :
_____/_____ |
Please indicate if you would like your newsletter sent to you by
Email Name :_________________________
Email address:_______________________ |
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Membership No .:
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Receipt No .:
______________________ |
Auth No .: |
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