Thank you for connecting with us. We will respond to you shortly.1 Application InformationMembership Information https://www.vana.com.au/wp-content/plugins/nex-forms-express-wp-form-buildertruemessagehttps://www.vana.com.au/wp-admin/admin-ajax.phphttps://www.vana.com.au/membership-applicationyes Application Information*Newsagency / Lottery Agency Name*Newsagency / Lottery Agency Address*Legal Name of Owner(s)/ Company Name*Name of Members*ABN*Full name of Partner (s) / Director (s)*Business Telephone NoFacsimile No*Mobile No*Email AddressTake Over DateResidential AddressTick TypeRetail OnlyDistribution OnlyRetail & DistributionTatts KioskVANA Membership ServicesNParcel/ BlueshyftNstockNadvertHR/ ERATM*Method of payment Credit Card (complete below) Monthly Direct Debit (complete below)DIRECT DEBIT REQUESTRequest and authorize VANA Ltd, to arrange for any amount VANA Ltd. (Debit User I.D. Number 042248) may debit or charge you to be debited through the Bulk Electronic Clearing System from an account held at the financial institution identified below subject to the terms and conditions of the Direct Debit Request Service Agreement (and any further instructions provided belo Name and address of financial institution at which account is held *Financial Institution nameName and address of financial institution at which account is held *Name of account*BSB Number*Account NumberAcknowledgement：By signing this Direct Debit Request you acknowledge having read and understood the terms and conditions governing the debit arrangements between you and VANA Ltd as set out in this Direct Debit Request and in our Direct Debit Request Service Agreement. Payment details *The Maximum Amount to be debited at any time isAmount of $*The first debit may be made onand at monthly intervals after thatCARD TYPE*Select Card Type VISA MasterCard*Card Holder's NameExpiry DateAmount$Commencement Date of Payment Next Membership InformationDo you hold contracts withTatts / TabcorpNparcel/ BlueshyftPostOtherPlease SpecifyDISCLOSURE STATEMENT: VANA collects and uses personal information about you to assist in providing our membership services to you, to communicate promotional offers and special events, and for our internal administrative, marketing, and planning requirements. If you do not wish to receive VANA newsletter or other information that we send to members, please contact VANA on (03) 8540 7000. We may provide your personal information to VANA industry partners (including organizations that may send you promotional materials), and to organizations that we use in the ordinary operation of our business. You may request access to personal information about you held by VANA by writing to our Office at our ordinary mail address. If at any time you provide the personal information of another person to us then you must first ensure that the person has read and understood this statement and separately consented to that personal information bring and disclosed by us for the above purposes. I, the undersigned, desire to become a member of the above mentioned Associations and agree, if elected, to be bound by the Constitution and Rules of such Associations. I also agree that if at any time I wish to resign from VANA, I must do so in writing as per Clause 11 of the Constitution and Rules. The above particulars are true in every respect.* Signature*Print Name*DateSubmit Your Application Back
