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| Please post to IBIS - Australia, P.O. Box 7092 SIPPY DOWNS QLD 4556 |
TO HELP US - PLEASE PRINT
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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 : |
$ 22.00 |
| Discount for Social Security Beneficiaries of $3.00- |
Sub-Total : |
$ 32.00 |
| Please quote your pension number : _____________________ |
Pen. Discount : |
__________ |
| Donations of $2 or more may be claimed as an e tax deduction |
+Donation Please : |
__________ |
| Bankcard / Mastercard / Visa (Please underline type) |
TOTAL : |
__________ |
Card Number :
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Cardholder Name : __________________________
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Signature :
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Expiry Date :
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Please indicate if you would like your newsletter sent to you by
Email Name :_________________________
Email address:_______________________ |
| Office Use Only : |
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Membership No .:
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Receipt No .:
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Authorisation No.
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