AUSTRALIAN COFFEE TRADERS ASSOCIATION
ACTA Incorporated
P.O. BOX 397
DOUBLE BAY
NSW 1360
Ph: 02 8084 9595 Fax: 02 8084 9595
Email: catherine@acta.org.au
MEMBERSHIP APPLICATION FORM
(To print, highlite form, select "copy" from the Edit menu, open Microsoft Word, paste to a new document, then print).
ABN 85 439 269 497
PO Box 397, Double Bay 1360 Phone 02 9362 9734, Fax 02 9326 1041
Application for Membership
Company Name…………………………………………………………………………………
Address…………………………………………………………………………………………..
State…………Post code…………Contact Name…………………………………………..
Telephone………………………………………Fax……………………………………..........
Mobile……………………………Email………………………………………………………..
(Please select one membership category)
Full Member,12 months; $500.00
□Grower/Exporter/Producer □Importers/Green Brokers
□Roasters / Wholesalers □Coffee Machinery Manufacturer
Associate Member, 12 Months: $250.00
□Food service/Distributor/Other
Payment can be made by,
□Cheque: (payable to) Australian Coffee Traders Association
□Direct Deposit: National Australia Bank, 082 128 01777 6542
□Credit Card (Visa, Mastercard, Amex):
Card Number…………………………………………………………………………………...
Card Name…………………………………………………….Expiry Date…………………
Signature……………………………………………………................................................
Please Complete, sign and return this form to the address above indicating the method of payment, A tax invoice will be forwarded when transaction completed along with currant Membership Certificate.
____________________________________________________________________
Office Use
Member Number………Approved…………………………………..Date………………..
