CMT Australia Membership Application

For $40 p/a per household, CMT Australia Members have access to

  • Informative Newsletters
  • Knowledge - Strategies to manage CMT
  • Support - through meeting other people with CMT
  • Seminar Downloads
Title *
Your first Name
Your last name
e.g. unit 4, apt 2, or 55
e.g. 2000
Australia
08 xxxx xxxx 0r 04xx xxx xxx
08 xxxx xxxx or 04xx xxx xxx
Please check the appropriate boxes:

The email entered above will become your alternate login option.  You will receive an email with notification that your profile has been created, with a link to log in and change/set your password.

Membership is $40.00 p/a per household

I wish to become a member for: (Select One Option) *

I wish to make a purchase

quantity x $5.00
number required - max 10
quantity x $5.00
quantity x $5.00
quantity x $5.00

If you wish to also make a donation, complete the section below:

enter name of person, organisation you are donating on behalf of

I would like this donation to be used for: (please ensure amounts entered in each area add up to the total donation amount above)

$10.00
$5.00
$5.00
$5.00
$5.00

Payment Options - to be completed via the shop after submission.

Please select one of the below options

Please deposit funds into the following account via your online banking or in person at branch:

ACCOUNT NAME: Charcot-Marie-Tooth Association Australia Inc. BSB: 032-069 ACCOUNT NUMBER: 158486 *Please use your last name as the transaction description.

Please make cheques/money orders payable to: Charcot-Marie-Tooth Association Australia Inc. Cheques/money orders may be posted to the following address: Charcot-Marie-Tooth Association Australia Inc. PO Box 493 Engadine NSW 2233

Include payment breakdown and member name on back of cheque

Credit Card payments are processed securely online by PayPal. Please click submit below to send details of your membership application to the National office.

To pay by credit card Proceed to membership page, select level of Membership, and proceed to check out. Complete your details and proceed to the payment page. Select the Pay with PayPal/Credit Card option, then the proceed to PayPal button. On this Page select the Pay by credit/debit card option and follow the prompts. Ensure the submit payment button is clicked for payment to be processed.

To pay by PayPal - follow steps above, on the screen after clicking Proceed to Paypal on payment Options, - Fill in email and password to login to your PayPal account, then follow promps, again ensuring the complete payment button is clicked for payment to process.

Donations over $2.00 are Tax deductible

A receipt will be issued, and a new member kit sent once payment is processed.

Bequests Your annual membership fee and donations go to the cost of publishing our Newsletter, maintaining our website, posting out the information to people (whether they are members or not), verbal advice over the phone or face to face in the office and giving any assistance we can. We also hold seminars and pay the expenses of medical professionals to give talks at interstate seminars. In addition to this we also give financial support to research. We would like you to think about a bequest to the Association. This would ensure that our work can continue well into the future serving members and fellow sufferers of CMT. OUR AIM IS TO ENHANCE THE QUALITY OF LIFE FOR PEOPLE WITH CMT.