Health and Community Services Union

11 December 2008

To become a member of the Health and Community Services Union (HACSU); download and print out the membership form; then complete and sign before returning to us by post to PO Box 206 Carlton South Vic 3053 or fax to 9650 8122

Alternatively you can fill out the form over the page and we will send you a membership pack.

Please provide full name as it appears on your Tax Return

Title
Last Name:
Given Names:
Preferred Given Name:
Date of Birth:
Home Address:

Suburb / Town:
Post Code:
Phone (Home):
Phone (Work):
Phone (Mobile):
E-mail Address [home]:
E-mail Address [work]:
Name of Employer:
Employer Address:

Suburb / Town:
Post Code:
Employer Phone:
Employer Fax:
Job Classification & Level (RPN 3; SOC2; DDSOC2, etc):
Hours:	(if part time) specify hours: hrs per fortnight

Please enter the text from the image for verification purposes:

I wish to become a member of the Health and Community Services Union, please send me the application forms: