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Staff Member Signup Form

PERSONAL DETAILS:
Title:
First Name *:
Middle Name:
Last Name *:
Birth Date:

Phone Home:
Phone Work :
Phone Mobile:

Fax Home:
Fax Work:

Email:

*MAILING ADDRESS :**
Street:

Suburb:
State:	Post Code:

PHYSICAL_ADDRESS:
Street:

Suburb:
State:	Post Code:

LOGIN DETAILS *:
UOW Username:
OR
External Password (you will be allocated username after signup):

STAFF DETAILS *:
Staff Type:
Staff Number:

Member Decleration *:

By agreeing to being a Member, you agree to be bound by the Terms and Conditions of Wollongong UniCentre LTD and the Wollongong UniCentre LTD consitution.

This constitution governs the activities of the organisation and its members. As a member, your liability should the company become insolvent, is limited to one dollar ($1.00).

I Agree

I also consent UniCentre to:

Send me annual report and election material via email
Send me UniCentre communications relating to my membership via email
Providing information about me to third parties


How did you learn about uniCentre Membership *:
	Email
	Website
	Colleague/Friend
	Poster
	Flyer
	Other
	Please Specify: