Complete the fields below or select from the drop down options where applicable:

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           People with Multiple Sclerosis – Victoria Incorporated

                                An endorsed tax deductable gift recipient  

ABN 73 104 198 752 

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Full Name of member with MS*
Street Address or PO Box for Correspondence*
Landline telephone number (if any)
Mobile Number*
eMail Address*
Type of Membership*
Full Member (as a person with MS)
Age Group*
30 to 39 years old
If an Associate membership application, what is the Name of the regular member?
Enter a comment or additional information (if any).
     (* = a required field)     
My IP Address has been logged as:

The completed form will be emailed automaticaslly to:-              

Michelle Raymond, Treasurer PwMS-V Inc

Roger Reece, Secretary PwMS-V Inc

You will also be entered in a draw for a VISA Gift Card to the value of $

The name of the winner will be drawn at our Annual General Meeting in November.