AUSTRALASIAN SPEECH SCIENCE AND TECHNOLOGY ASSOCIATION, INC.
ABN: 90 905 029 500

To: Shunichi Ishihara, ASSTA Treasurer

_____________________________________________________________
Name

_____________________________________________________________
Address

_____________________________________________________________
Email Address

Tick here __ if your address details should be updated on the
             ASSTA membership database.

Payment Options (please tick):
  __  Cheque, bank draft or money order enclosed, made out to
      ASSTA, Inc. (in Australian dollars, please).

  __  Please charge to my credit card account:
        __ VISA     __ MasterCard     __ BankCard

      Amount Paying: ___________ Australian Dollars


      ____________________________________	__________________
      Card Number                               Exp. Date (MM/YY)

      ____________________________________
      Cardholder Name

      ____________________________________
      Signature


Please print out and post/fax to:

Shunichi Ishihara                 Fax:   (02) 6125 3144
ASSTA Treasurer
The Australian National University
Faculty of Asian Studies
The Japan Centre
Canberra  ACT  0200
AUSTRALIA

Email Inquiries to: Treasurer@assta.org