APANA Individual Membership Application Form

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APANA is the Australian Public Access Network Association. Application for
membership should be made by completing and signing this form and posting it
to the following address. Applications for membership should be accompanied
by a cheque or money order for the first year's membership fee and any other
fee (where applicable.)

This form is for individual membership only. Non-profit organisations
wishing to apply for membership of APANA should use the "Organisational
Membership" form instead.

This form was generated automatically and you should check ALL information
supplied before sending it. Make sure YOU SIGN IT, and add a cheque/money
order (NO CASH) with the correct amount:  

State: VIC		----->	Total Fee: $ 60


then send it to the following address. Thank you.
Cheques should be made payable to "APANA Inc." and sent to:

                        REPLY PAID 1250
                        APANA
                        P.O. Box 1189
                        Camberwell
                        Victoria 3124

This form was last modified January 1996.

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PERSONAL AND CONTACT INFORMATION

This information is required for APANA membership records and for us to
contact you should the need arise. This information will not be published
and will only be made available to authorised APANA representatives.

Given Name:		david

Surname:		smith


Business Hours Telephone Number:	03 95019506

After Hours Telephone Number:		03 95789569

Postal Address: 37 spring rd, sth caulfield	melbourne   VIC

Existing E-mail address (if any): dj@minkirri.apana.org.au

Are you aged over eighteen?       Yes  /  No

(If not, please ensure that your parent or legal guardian signs this form).
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LEGAL DECLARATION

This declaration is required before your application for membership of APANA
can be processed. Please be sure that you have read and understood the rules
of membership and the network acceptable use policy supplied in the
information kit before signing this declaration.

I certify that the above personal details are true and correct and that I
have been provided with a copy of the APANA rules of membership and the
APANA network acceptable use policy and that I agree to abide by the
conditions contained in those documents along with any new or altered
policies or conditions which may from time to time be determined by the
Management Committee of APANA.

Signed ________________________________________        Date

Please remember to include payment of the appropriate fee!

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GUARDIANS SIGNATURE (if applicant is under 18 years of age)

The Internet allows access to a wide range of information, some of which may
offend or be considered inappropriate for people under 18. It is not
possible for APANA to censor or control the information which can be
accessed through the Internet. Members (and where the member is less than 18
years of age, their parents or guardians) take full responsibility for any
information accessed via the APANA network. Your child can benefit
enormously from access to the Internet. You may wish to explore this new
environment with your child to better understand the issues surrounding it.

Signature of Parent/Guardian:



Signed ________________________________________        Date

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FOR OUR INFORMATION

You do not need to provide this information unless you wish, but if you do
it will help your regional committee to better plan services to members in
your region. Please understand that this is not an order form, and that
APANA does not guarantee availability of any service.

For what reason are you seeking membership of APANA?

What type of computer system do you use?

     Amiga
     Macintosh
     Microsoft DOS
     Microsoft Windows
     Unix
     other (please describe:                        )

What type of network access do you expect to use?

     login account
     uucp
     SLIP/PPP
     other (please describe:                        )

What speed of modem do you expect to use?

     2400 bps
     14400 bps
     28800 bps
     other (please describe:                        )

Do you operate a public access system?          Yes  /   No

If yes, how many simultaneous users do you expect on your system?

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