Application for Membership

"We are in a fantastic position, at the right time and place, to halt this cycle of decay and to start a new one [civilization] on Earth. And I believe we should overtly do so." The Special Zone Plan - LRH

I hereby apply for Membership with the NSW Chapter of CCHR. I know that my membership and other contributions to CCHR are vital actions that will help to quickly end the current abuses in the field of Mental Health. I am therefore taking responsibility and making this contribution towards cleaning up the field of Mental Health for the benefit of all mankind.

First Name *
Last Name *
Company:
Address *
Suburb / City *
State *
Postcode *
Country *
Home Phone
Work Phone
Mobile
Email *
Date of Birth * (dd/mm/yyyy)

Membership Type


Basic Membership ($30) Family Membership ($300)
Annual Membership ($110) Company Membership ($500)
 
Lifetime Membership ($1,000) Defender Membership ($25,000)
Advocate Membership ($2,000) Gladiator Membership ($50,000)
Reformer Membership ($5,000) Guardian Membership ($75,000)
Protector Membership ($10,000) Champion Membership ($100,000)
 
Please do NOT publish my name in the CCHR NSW newsletter.

Payment: Please nominate how you wish to make a payment.


Cash or Cheque Periodic Payment / Internet banking
Money Order Credit Card
 

Thank you for your support. CCHR NSW will contact you to confirm the details.


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