PO Box 2040

Kelvin Grove Q 4059
Email: dweek2@eq.edu.au
Web: www.pa.ash.org.au/atomqld/

Membership Application Form
ATOM QLD INC is a professional association for media teachers. We focus our attention on Queensland
curriculum matters while also sharing classroom resources and general insights into current directions
and issues in media education through:
! organising relevant professional development activities for our members including partnerships
with Cinesparks, Australian Children’s Television Foundation, Dendy Brisbane and MovieMania
! providing professional practice sharing opportunities through an ATOMQ members site, our online email network and regular swap-shop meetings
! regular updates on competition opportunities and free screenings/previews for movies
! discounted subscription to Australian Screen Education and Metro Magazine with membership

"---------------------------------------------------------------------------------------------------------------On payment, this form becomes a Tax Invoice. ATOM QLD INC’s ABN: 51 081 593 357
Please send to: ATOM QLD INC, PO Box 2040, KELVIN GROVE Q 4059
Please do not email this information.
What type of member would you like to be?
Please Note: ATOMQ members can combine their Membership with subscription to Australian
Screen Education or both Australian Screen Education and Metro Magazine and take advantage of a
$5 discount.

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Corporate Membership($105)
(Up to 4 nominated members)

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Corporate Membership with ASE Subscription ($195)
Corporate Membership with ASE and Metro Magazine Subscriptions ($255)
Individual Membership ($55)
Individual Membership with ASE Subscription ($122)
Individual Membership with ASE and Metro Magazine Subscriptions ($168)
Student ($25)
Student Membership with ASE Subscription ($85)
Student Membership with ASE and Metro Magazine Subscriptions ($120)

(Payment and contact details on page 2 – PLEASE ATTACH SECURELY TO THIS PAGE)

Individual and Student membership:

NAME: ________________________________ SCHOOL / INSTITUTION: ____________________________
PHONE (W): __________________ FAX (W): ___________________ PHONE (H): ____________________
EMAIL: _______________________________________________ MOBILE: __________________________
POSTAL ADDRESS: ________________________________________________________________________
________________________________________________________________________

Corporate membership:
SCHOOL / INSTITUTION: ____________________________
PHONE: __________________ FAX : ___________________
POSTAL ADDRESS: ________________________________________________________________________
________________________________________________________________________
NAME #1: ______________________________ EMAIL: ___________________________________________
NAME #2: ______________________________ EMAIL: ___________________________________________
NAME #3: ______________________________ EMAIL: ___________________________________________
NAME #4: ______________________________ EMAIL: ___________________________________________

! I enclose a cheque/money order for $ __________ made payable to ATOM Qld Inc.
or charge my ! Bankcard ! MasterCard ! Visa ! Amex ! Diners Club

Expiry date

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Cardholder Name:______________________________ Signature:__________________________
Card No:

_ _ _ _ /_ _ _ _/_ _ _ _/_ _ _ _
Office use only...
Cheque / money order date: _______________
Receipt number: ________________________
Date presented to bank: __________________