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I/We authorise the HSUWA (User ID 063 168) to arrange for funds to be debited from my/our account at the financial institution identified above and as prescribed on this form through the Bulk Electronic Clearing System. This authorisation is to remain in force in accordance with the terms described in the HSUWA Direct Debit Customer Service Agreement which is available on request.

I hereby apply to be a member of the Health Services Union of Western Australia and Health Services Union WA Branch (HSUWA/Union). Information about the Union and its Rules can be found on the Union website or by calling the Union.

In making this application I declare that the information I have given is correct. I acknowledge that cancellation of my membership will be submitted in writing and that membership contributions paid prior to requesting membership cancellation will not be refunded.

The Union’s New Member Support Policy applies to all new or returning Members. The insurances of Professional Indemnity Insurance and Journey Cover Insurance will apply to Members in accordance with their policy terms and only to employed, financial Members of the Union. The terms of these insurances are available on request.