B.        Member Details

Please complete:

Organisation:

Name of Individual or Accredited Representative of the Organisation:

Prof   Dr   Mrs   Mr   Ms
First Name   Surname

Postal Address

Town:   State    Postcode

Tel (BH):    Email: 

Fax:           Mobile:

Please indicate if you would prefer future correspondence from ADCA in electronic format.

D.       Membership Information

To enable us to better advocate on behalf of the AOD sector and to improve the delivery of services to members, it would be appreciated if you could provide the following information for inclusion in the ADCA database:

How many staff does your organisation employ?
(in terms of "equivalent full time positions")

How many volunteers does your organisation have?

What would you describe as the core business of your organisation? (please select from the following)

Does your organisation specifically target any particular population group? (please select from the following)

E.       Declaration

In making this application, I/We declare my/our support for the mission of ADCA:
ADCA, as a national peak body for the alcohol and other drugs sector, is committed to the principle of harm minimisation. ADCA works collaboratively with the government, non-government, business and community sectors to promote evidence-based, socially just, approaches aimed at preventing or reducing the health, economic and social harm caused by alcohol and other drugs to individuals, families, communities and the nation.

Signature:........................................................  Date:  ....../....../......
(must be signed by nominated individual)

Name:

Position:

Agreement to conditions of use:

ADCA membership entitles our organisation to individual use only of the NRC electronic services.

The use of NRC Electronic Services including viewing, printing and downloading of individual articles is for the purpose of study, teaching and research. That the downloading of an entire journal issue in a systematic fashion is strictly prohibited and that information must not be used for commercial purposes or re-sold in any way.

Any NRC material borrowed by me that is lost or returned damaged will incur a fine to pay for the repair or replacement cost.

Signature:........................................................  Date:  ....../....../......
(must be signed by nominated individual)

Name:           

Position:

Up to two additional individuals of an organisation may be granted access to the NRC. The nominated individuals must sign the Agreement to conditions of use below:

Second nominated user of electronic journals

Agreement to conditions of use:

ADCA membership entitles me to individual use only of the NRC electronic services.

The use of NRC Electronic Services including viewing, printing and downloading of individual articles is for the purpose of study, teaching and research. That the downloading of an entire journal issue in a systematic fashion is strictly prohibited and that information must not be used for commercial purposes or re-sold in any way.

Any NRC material borrowed by me that is lost or returned damaged will incur a fine to pay for the repair or replacement cost.

Signature:........................................................  Date:  ....../....../......
(must be signed by nominated individual)

Name:

Phone:     

Email:

Third nominated user of electronic journals:

Agreement to conditions of use:

ADCA membership entitles me to individual use only of the NRC electronic services.

The use of NRC Electronic Services including viewing, printing and downloading of individual articles is for the purpose of study, teaching and research. That the downloading of an entire journal issue in a systematic fashion is strictly prohibited and that information must not be used for commercial purposes or re-sold in any way.

Any NRC material borrowed by me that is lost or returned damaged will incur a fine to pay for the repair or replacement cost.

Signature:........................................................  Date:  ....../....../......
(must be signed by nominated individual)

Name:

Phone:    

Email:

F.      Payment Details

A Cheque/Money Order made payable to 'ADCA' is enclosed
OR
Please charge the credit card indicated

Visa      Mastercard     Bankcard

Card Number: Exp Date:

Signature:     Date:

Card Holder: 

Please check all details are complete, print form, sign it and then fax to (02) 6281 0995.

Thankyou.

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