HACCI Membership Application Form

Membership Details

Please select membership type*:

Please select state*:

Please select membership category*:

Corporate Membership	$495	(includes 4 members)
Business Membership	$250	(includes 2 members)
Professional Membership	$250	(includes 2 members)
Individual Membership	$140
HACCI Young Professionals	$ 80

Applicant Details

First Name*
Date of Birth*
Telephone*
Address*

Last Name*
Email*
Mobile*

If applicable

Company Name
Position/Title
Website

Industry
Number of employees
Company Address

Additional Applicants

2nd Member

First name
Telephone
Address

Surname
Position/Title
Mobile

3rd Member

First name
Telephone
Address

Surname
Position/Title
Mobile

4th Member

First name
Telephone
Address

Surname
Position/Title
Mobile

*The HACCI office will contact you on receiving your application form to process payment.
*A tax invoice & receipt will be sent to you within 28 days from receipt of this application.
*Your personal information will be handled according to HACCI’s privacy policy.