Personal Details

1. *Title: Please select Miss Ms Mrs Dr Mr Other
3. *Given Name:
4. *Family Name:
5. *Address:
7. *Suburb:
8. *State: Please select Australian Capital Territory New South Wales Northern Territory Queensland South Australia Victoria Tasmania Western Australia
9. *Post code:
10. *Home Phone:
11. Mobile:
12. * Home Email Address:
13. Work Email Address:
14. *Date of Birth: Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913
15. *Gender: Please select Male Female Other

Job Details

16. *What is your job title?:
17. *Name of employer?:
18. Location of employer?:

Mortality Benefit: Nomination of Beneficiary

The Rules of the AFULE provide that a mortality benefit be paid if you pass away while a financial member of the Union. Please nominate the person you would like the benefit paid to.

19. *Title: Please select Miss Ms Mrs Dr Mr Other
21. *Given Name:
22. *Family Name:
23. *Address:
25. *Suburb:
26. *State: Please select Australian Capital Territory New South Wales Northern Territory Queensland South Australia Victoria Tasmania Western Australia
27. *Post code:
28. *Home Phone:
29. Mobile:
30. Security Code:
     * 
    
31. Send
32. Fields marked with an asterisk (*) are required.