MEMBERSHIP FORM APPLICATION / RENEWAL 2011 Reply Paid PO BOX 418 FORTITUDE VALLEY QLD 4006 Ph: (07) 3839 7020 Fax: (07) 3839 7021 Freecall: 1800 177 938
members@qieu.asn.au www.qieu.asn.au Membership Number
Collection of this information complies with the provisions of the Privacy Amendment (Private Sector) Act 2000
PERSONAL DETAILS Rev, Dr, Mr, Mrs, Miss, Ms Family Name_______________________ Given Names_________________________________ Home Address____________________________________________________________________________________________ ___________________________________________________________________________________ Postcode_____________ Home Phone________________________
Mobile Phone________________________
Home Email________________________________________
Date of Birth_________________
Work Email_________________________________________
Employed at_____________________________________________
Suburb of School_______________________________
Do you wish to be recorded as being of Aboriginal or Torres Strait Islander descent?
Yes
Do you wish to receive additional information about Teachers’ Union Health?
Yes
I hereby wish to apply for/renew membership of the IEUA-QNT. In addition I appoint the IEUA-QNT as my agent and I authorise IEUA-QNT to represent me in any industrial matter or dispute. This authority to represent me may be withdrawn by a written request. Where eligible, members of the IEUA-QNT will also be registered as members of QIEU.
Signature___________________________________________
Date_________________________
An administration fee equivalent to six weeks of membership is non-refundable.
CLASSIFICATION Teaching Staff Teacher / Instructor Graduate Teacher Principal Deputy Principal Assist. Principal (RE) Assist. Principal (Admin) Assist. Principal (Other) Experienced Teacher PAR Advanced Skills Teacher Senior / Leading Teacher ELICOS Teacher School Counsellor Other________________ Associate Retired (not working) School Officer School Officer Business Administrator Other________________
Band _____ Step ____ or Level _____ Band _____ Step ____ or Level _____ Level _____ Level _____ Level _____ Level _____ Level _____ Level _____ Level _____ Level _____ Level _____ Year _____ Year _____
Services Staff Boarding House Staff Janitor Caretaker Groundsperson Security Staff Gardener Laundry Staff Domestic Staff Bookhire / Uniform Shop Catering / Canteen Other________________ Early Childhood Staff Early Childhood Teacher Early Childhood Assistant Director of Early Childhood
Level _____ Step _____
HOURS OF EMPLOYMENT ALL MEMBERS TO SELECT FROM THE OPTIONS BELOW Full Time _______hrs p/wk Part Time Term Time _______hrs p/wk Contract _______hrs p/wk Job Share _______hrs p/wk Casual _______hrs p/wk
SCHOOL OFFICERS AND SERVICES STAFF ALSO NEED TO COMPLETE THE QUESTIONS BELOW Number of weeks employed per year __________ Is your pay annualised?
Yes
No
Gross annual income for the 2011 year $__________
LEAVE Long Service Leave Maternity Leave Extended Sick Leave
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Study Leave Leave Without Pay Other________________
Expected dates of absence ____ /____ /____ - ____ /____ /____ Component that is paid leave ____ /____ /____ - ____ /____ /____
1/10/10 1:46 PM
Membership Number
METHOD OF PAYMENT
No change to periodical arrangements from 2010 Start periodical direct debit or credit card payments (Please complete section A or B) Full Payment - Tick Schedule below (fees paid in full are for the period 01/01/2011 – 31/12/2011) Credit Card (Please complete section B) Cheque for $____________ is attached BPAY - continuing members only (See at right for payment details)
Biller Code: 172254 Reference:
SECTION A - DIRECT DEBIT AUTHORITY I / We request that you, the IEUA-QNT, User ID No. 084413 arrange for my membership fees to be deducted from the account listed below. This authority will remain in force from year to year until I advise otherwise in writing. Name_________________________________________________
Fortnightly Periodical Payments Processed on the Friday of your pay week
Bank and Branch________________________________________ Next Pay date___________________ BSB_____________
Account____________________________
Address _______________________________________________
Monthly Periodical Payments 20th of each month or the next working day
Signature/s _____________________________________________
Date_________________________
If debiting from a joint account, both signatures are required
SECTION B - CREDIT CARD AUTHORITY I / We request that you, the IEUA-QNT, arrange for my membership fees to be deducted from the credit card below. For Periodical payments this authority will remain in force from year to year until I advise otherwise in writing.
Visa Card
MasterCard
Expiry_____/_____
Fee in Full Monthly Periodical Payments 15th of each month or the next working day
Cardholder’s Name______________________________________ Signature______________________________________________ Date_________________________
Quarterly Periodical Payments 1st working day of January, Apr il, Ju ly and October Half Yearly Periodical Payments 1st working day of January and July
SCHEDULE OF FEES (PLEASE TICK THE RELEVANT BOX)
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Fortnightly Monthly Quarterly Half Yearly Monthly Gross Annual Income: Direct Debit Direct Debit Credit Card Credit Card Credit Card Less than $20,000 $6.95 $15.05 $47.50 $95.00 $15.85 $19.85 $62.75 $125.50 $20.90 Between $20,001 - $25,000 $9.15 $24.80 $78.25 $156.50 $26.10 Between $25,001 - $30,000 $11.45 $29.75 $94.00 $188.00 $31.35 Between $30,001 - $35,000 $13.75 $34.75 $109.75 $219.50 $36.60 Between $35,001 - $40,000 $16.05 $39.80 $125.75 $251.50 $41.90 Between $40,001 - $45,000 $18.40 $44.65 $141.00 $282.00 $47.00 Between $45,001 - $50,000 $20.60 $49.70 $157.00 $314.00 $52.35 Between $50,001 - $55,000 $22.95 $54.65 $172.50 $345.00 $57.50 Between $55,001 - $60,000 $25.20 $56.90 $179.75 $359.50 $59.90 Between $60,001 - $65,000 $26.25 $58.90 $186.00 $372.00 $62.00 More than $65,000 $27.20 $39.80 $125.75 $251.50 $41.90 Graduate Teacher - 1st year of appointment $18.40 $7.15 $22.50 $45.00 $7.50 Associate Retired $3.30 $7.15 $22.50 $45.00 $7.50 Maternity Leave $3.30
Full Rate $190.00 $251.00 $313.00 $376.00 $439.00 $503.00 $564.00 $628.00 $690.00 $719.00 $744.00 $503.00 $90.00 $90.00
Calculation of your fees will be based on your gross salary/wage as at 1 st January 2011 Your fee is based on pre salary packaging arrangements Office Use Only Amount: ____________________
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Schedule____________________
Initials____________________
Date_____ /_____ /_____
1/10/10 1:46 PM