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* 1. Full Name:

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* 2. AusIMM Member Credentials:

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* 3. Email address:

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* 4. Where are you located?
(Please list your suburb)

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* 5. I am interested in applying for the following position/s in the Southern Queensland Branch committee

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* 6. Were you recommended to join the AusIMM Southern Queensland Branch?
If so, please list who by:

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