Business Contact (required*):

Home/Mobile Contact (required*):

Email Address (required*):

Name of Company:

Position:

Industry:

Name of University (e.g. Curtin University) (required*):

From (Year) (e.g. 1994) (required*):

To (Year) (e.g. 1997) (required*):

Name of University:
(only if applicable, otherwise leave blank):

From (Year):
(only if applicable, otherwise leave blank):

To (Year):
(only if applicable, otherwise leave blank):

Please state activities that interest you:

Non-Business Activities
(e.g. golf, tennis, social gatherings) :

Business Activities
(e.g. investment talks, industry updates) :


Would you be interested to join as a committee member?
Yes No
Note: we will contact you on your Home Contact if you state "Yes"