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First Name: *

Last Name: *

Home Address Line 1: *

Home Address Line 2:

Suburb *

Postcode: *

Primary Phone Number: *

Alternative Phone Number:

Primary Email: *

Alternative Email:

Date of Birth: *

Gender *

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Occupation/Profession: *

Do you work for more than one employer? *

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Primary Employer Name: *

Workplace/Site Address: *

Job Title: *

How many hours do you work per week? *

Employer Name (Secondary): *

Workplace/Site Address: *

Job Title: *

How many hours do you work per week? *

There are three ways to pay your union membership fees. The easiest and most popular is a fortnightly direct debit from your nominated bank account. If you'd prefer to pay using credit card, please be aware that you can only pay on a quarterly or annual basis.

The amount you pay depends on the number of hours you work per week.

Click here for a copy of our current fee schedule.

Please note, if you nominate to pay your membership fees via credit card one of our staff members will be in touch with you shortly to confirm your credit card details and finalise your application.

How would you like to pay? *

Fortnightly Direct Debit (Bank Account)
Quarterly Payment (Credit Card)
Annual Payment (Credit Card)

Bank Account Holder Name: *

BSB: *

Account Number: *

I have read and understood the direct debit service agreement and authorise HSU SA/NT to debit my nominated bank account every fortnight for the purposes of paying my membership fees: *

To finalise your application please complete the following declaration.

I hereby appoint HSU SA/NT (the Union) as my agent for the purposes of the giving and accepting of civil liability and professional indemnity insurance in accordance with the Insurance Contracts Act (1984) and its regulations. I understand that as an agent, the Union is not responsible for any acts, omissions or negligence on the part of the insurer. I undertake to report any facts or circumstances which may give rise to a claim under the policy to the Union as soon as I become aware of any facts or circumstances: *

I have read and accepted the terms and conditions. *

Please send me information on HSU campaigns and member offers:

What is 12 minus 4? *

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