First Name*Surname*Address*Surburb*Postcode*State*Country*Phone NumberMobile Number*Date of Birth Date Format: DD slash MM slash YYYY Email* Please select all that apply. I have been diagnosed with an autoimmune illness I have a family member or friend who has an autoimmune illness I am a health professional that has an interest or aids in the health management of people living with autoimmune illnesses I am a person that has a general interest in autoimmune illnesses Which autoimmune illnesses have you been diagnosed with?Which autoimmune illnesses does your family member or friend have?Newsletter I would like to receive a hard copy of the newsletter Payment OptionsDirect DepositChequePaypalAmount Price: $ 20.00 Terms & Conditions* I hereby apply to become a member of the above mentioned incorporated association. In the event of my admission as a member, I agree to be bound by the constitution of the association for the time being in force. I understand there is no set membership subscription or membership registration fee. If I choose to do so, I can make a donation.