1. |
First Name : |
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| 2. |
Surname : |
Title:
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Add/Update
Information ? |
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| 3. |
Address
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(optional) |
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Suburb: |
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Postcode : |
State :
* Brisbane/Sydney/Wollongong ONLY
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| 4. |
Telephone - Home : |
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Telephone - Work : |
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Telephone - Mobile : |
Plan:
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Mobile Provider:
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| 5. |
Email Address : |
* We may email you from time to time
regarding groups, enter
'OPT OUT' in the Email Address if you do not wish this to happen. |
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Email Check
Frequency : |
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| 6. |
Your Gender : |
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What is your
marital status : |
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What is your
Nationality : |
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Date of Birth
: |
Day
(01-31) / Month (01-12) / Year (1900-) |
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Areas in
which you would prefer to attend groups: |
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| 7. |
Job Title : |
(10 characters
max.)
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Employeed
Status : |
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Self Employed
: |
No. of Employees: |
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Which of these would best describe your occupation
(ABS codes) : |
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What Industry Type
: |
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Suburb in which you
Work: |
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What is your
partners occupation (if applicable) |
(10 characters max.) |
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| 8. |
Do you drink ? (mark
whichever apply) : |
Beer
Wine
NON-Drinker
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| 9. |
Credit cards held
(choose whichever apply) : |
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10. |
What bank do
you have your main account with : |
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What Building
Society do you have an account with : |
(10 characters max.) |
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What type of
account(s) do you have? |
Savings Account
Cheque
Investment
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11. |
These questions relate to your main car(s): |
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Car Make
: |
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Car Model : |
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Year of
Manufacturer : |
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Car insured
with : |
(10 characters max.) |
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Is this a
company car : |
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Are you a
member of the NRMA : |
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12. |
Do you have
pets (how many): |
Cat Dog |
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13. |
Do you have any children living at home, if so what is their year of
birth : |
Child BOY, year of birth (YYYY):
Child BOY, year of birth (YYYY):
Child BOY, year of birth (YYYY):
Child GIRL, year of birth (YYYY):
Child GIRL, year of birth (YYYY):
Child GIRL, year of birth (YYYY):
Are they interested in attending Groups ? :
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14. |
Into which of the categories listed does the income of the entire
household belong? (*ABS
categories) |
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15. |
Do you smoke
cigarettes: |
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Do you own a
Personal Computer : |
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Do you wear
spectacles/ contact lenses : |
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Do you travel
on business : |
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Do you have
Pay TV : |
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Do you have
Private Health Insurance with : |
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How did you
hear about us: |
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Comments : |
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Thank you |
