Membership Application Form Membership Application Form Step 1 of 2 50% Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail Type of MembershipPlease see above for further information on membership, the costs and benefitsType of Membership I am seeking Full Australian – working as a paid life story professional. Full International – as above but living outside of Australia. Allied – editors, printers, publishers etc supporting life story professionals. Associate – emerging life storyteller not yet eligible for full membership. Supporter/Friend Philanthropic contributor I am currently working as a Life Story Professional Full Time Part Time Sub-contractor Full MembershipFull MembershipBusiness NameBusiness Website (1)Business Website (2)This field is hidden when viewing the formOtherPrimary Business Service Books Film Audio Mixed Media Photographic Other My qualifications to support a full membership are:BooksAudios or VideographyLife Story Writing/Autobiography/OtherCoaching or Mentoring (Please provide 3 client's names and the year the service was provided)Do you have any other projects, experience or qualifications you wish to list to support your application?Business Description for website (limit 70 words)Skills for Public Directory on websiteReference*Max. file size: 64 MB.Please provide a written character or professional reference, including the referee’s phone number and email address.Referee's name* First Last Referee's email* Referee's phone*Associate MembershipAssociate Membership Starting out Pausing career Hobby This field is hidden when viewing the formYour website or email addressThis field is hidden when viewing the formPhone number for websiteThis field is hidden when viewing the formAllied Industry that supports Life StoriesAllied Industry that supports Life StoriesAllied Membership (related registered business and qualifications in field that support Life Stories) Editor Educator Publisher Illustrator Literary Agent Bookseller Business Description for website (limit 70 words)Skills for Public Directory on websiteWould you like to be contacted regarding additional advertising with us Yes No Reference*Max. file size: 64 MB.Please provide a written character or professional reference, including the referee’s phone number and email address.Referee's name* First Last Referee's email* Referee's phone*Supporter/FriendSupporter/Friend – I am not a Life Story Professional or Vendor but interested in Just connecting Donor Volunteer Philanthropic contributorSupporting MembershipSponsor Membership – Individual or Organisational Platinum Gold Silver I am interested in being a Philanthropic contributor and/or making a Bequests Platinum Gold Silver CaptchaI am prepared to abide by the LSA Code of Ethics (ticking Yes is equivalent to your signature that you will abide. Ticking No means you are not eligible for membership of this Association)* Yes No CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Have any questions? Contact Us
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