Please complete separate form for each application

Fax to 1300 139 556 or Post to P.O. Box 270 Surrey Hills Vic 3127

Please provide the following details.

Personal Details

Mr/Mrs/Ms  Full Name 

Address 

City/Suburb/Town  State  Post Code 

Occupation 

Which superannuation scheme are you a member of? [please tick relevant box]
Local Government Superannuation Scheme
Energy Industries Superannuation Scheme
FuturePlus Super

Phone (Home)      Phone (Business) 

Mobile Phone       

Email 

Payment Details

Please select card type by placing a tick or a "Y" in the relevant box:
 Mastercard  Visa  Bankcard

Name on Card 

Card Number      Expiry Date     

I authorise you to charge the amount of to the nominated card.

Signature



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Date      /     /

Alternatively, send a cheque or money order made payable to MEMBERBenefits P.O. Box 270 Surrey Hills Vic. 3127

All information will be treated with strictest confidence