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Membership Application / Expression of Interest Form

Membership Application Form

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Joining as a member

Agencies and organisations, and individuals may join.

Complete the online form below or download and print, mail or fax the membership form to VICSERV available at right.
Alternatively you can call Psychiatric Disability Services of Victoria (VICSERV) on (03) 9519 7000 and request an application for membership form be faxed or emailed to you.

Membership Fees

Funding level	Ordinary Membership	Associate Membership
Concession rate*	Not available	$45.00
Individual rate*	Not available	$85.00
$0 - $50,000	$115.00	$85.00
$50,000 - $200,000	$170.00	$120.00
$200,000 - $500,000	$210.00	$180.00
Over $500,000	$265.00	$210.00

All rates are inclusive of the GST

An initial pro-rata payment is due to bring your membership in line with the financial year.
We will invoice you for the amount due.

If you have any queries regarding membership fees, please phone (03) 9519 7000 or email vicserv at vicserv.org.au

*Denotes an entry is required

Membership joining form

*Name
*Organisation
*Address
*Suburb
Country
*Postcode
*Email
*Phone
Fax
Membership type	Full Associate Individual
If you are a Multi Site Organisation requesting membership, please select the number of sites that you manage.
If other selected, please enter the number
Does your organisation offer psychiatric specific support services?	Yes No
If yes, what types? (please check all that apply)
PSR Day Programs
Home Based Outreach
Respite Care
Mutual Support/Self Help
Residential
Statewide
*Funding Level	The funding level of your organisation per annum (for billing and statistical purposes):
The above named organisation (or individual) hereby expresses interest in membership of Psychiatric Disabilities Services of Victoria (VICSERV) Inc. and nominates the above named person as the Contact person for all correspondence. Upon acceptance of this application, Psychiatric Disabilities Services of Victoria (VICSERV) Inc. is authorised to insert the name of this organisation (or individual) in the register of members of the incorporated association. We hereby agree to abide by the Rules of Psychiatric Disabilities Services of Victoria (VICSERV) Inc.
*Per Official Representative
*Position
An initial pro-rata payment is due to bring your membership in line with the financial year. We will invoice you for the amount due.
Please supply a copy of your last Annual Report, and a copy of Statement of Purposes if an organisation, or information about your service.