PARTNERSHIP APPLICATION
Please fill out this form and click submit.
Name
*
Email
*
This address will receive a confirmation email
Phone
*
Address
*
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ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Spouse (if applicable)
PARTNER CONTRIBUTION
Pay by Direct Debit Option
Please select all that apply.
I will transfer monthly
Please specify amount:
CI EAGLENET ACCOUNT DETAILS
BSB: 014 228
Account: 3526 29742
*Please use your name and "partners" as description when transferring
Pay by Credit Card Option: Please select monthly amount to be deducted:
Please select all that apply.
$30
$50
$100
$250
$500
Other (please specify amount)
PAY BY
Please select all that apply.
VISA
MASTERCARD
CARD NO.
EXPIRY DATE
NAME ON CARD
Submit
Description
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