[A] Application for Public Service Association of NSW Membership

To be returned to Membership Section, PSA/CPSU, GPO Box 3365, Sydney 2001 for processing.

(Please use BLOCK letters or type all details)

I,

Home address:

State & Postcode

Employing body (Department, School, Authority etc)

Payroll Serial Number

Fee payable ($ & period)

Occupation

Work address

State & Postcode:

Telephone (home)

Telephone (work)

E-mail address

Date of appointment to service _____/_____/_______

Date of birth _______/______/_______

(Optional item) If you are an Australian Aboriginal or Torres Strait Islander member, please tick this item. This will assist our Aboriginal Liaison Officer to maintain an accurate list of members, which helps us provide a better service for members. ___________

I agree that a copy of this form (whether copied by photocopy, microfilm, facsimile or otherwise) may be used or dealt with as if it were the original.

I have read and understand the information above relating to financial obligations and the circumstances and manner in which I may resign my membership.


Signature

Date ________/_______/_________

When you have read the obligations print out this form, complete it, then sign it.

The completed form must be posted to us as we need your signature.