Exit Membership Form

Introduction Exit International Membership provides Exit International is a non-profit, death-with-dignity organization • Exit Workshops (conducted regularly in all states of Australia, that operates internationally. NZ & other countries) What makes Exit special is that • Peanut Project (peaceful pill) we provide practical services for • Private Clinic Visits (upon our members, placing secondary request) importance on the possible future • Exit R&D (Pill research, introduction of a VE law. Carbon Monoxide, Exit Bags/Helium) Background • Exit Online Forums at Exitinternational.net Exit International was founded by • Nancy’s Friends Network Dr Philip Nitschke in 1996. • Deliverance newsletter Formerly called VERF (Voluntary (monthly) Euthanasia Research Foundation), • Living Will Register Exit International has grown to a • Discounts on Exit membership of around 3000 in Publications / Exit Australia, NZ and other countries. Conferences • Exit Lapel Badge Dr Nitschke came to prominence • Exit Membership Card in the mid 1990s when he became the first doctor in the world to Exit International’s sole source of administer legal, voluntary income is member donations. euthanasia. This was during the Please support the work of Exit by time of the Rights of the becoming a member. Terminally Ill Act in the Northern Territory. Exit International

PO Box 37781 Exit International is head- Darwin NT 0821 quartered in Darwin, Australia. Australia

Phone 0500 83 1929

Fax 08 8983 2949 OR online at: http://www.exitinternational.net [email protected]

Exit International Membership/Donation Form Final Exit (Australia) ABN 96 102 986 005

First Name…………………………….………Last Name……………………………………………………

Address……………………………………………………………………………………….……………………….

……………………………………………………………………………….…….Postcode………………….....

Email…………………………………………………………………………………………………………………….

Date of Birth……………………………….Telephone…………………………………………..………….

Occupation (if retired pls state previous)………………………………………………..…………

How did you hear of Exit?......

I am donating $………………..……(amount) on ……………….……….……(today’s date)

The average annual donation is A$100

Life Membership is gratefully granted for donations of >$1000

I am donating by:

Cheque/ Money Order Visa Mastercard

Bankcard (Australian $ Cheques ONLY please)

Credit Card No……………………….…………………………..…..Name on Card……………………………

Signature…………………………………………………………Expiry Date…………………….…………….…

Mail Exit International Ph 0500 83 1929 PO Box 37781 Fax 08 8983 2949 Darwin NT 0821 [email protected] Australia www.exitinternational.net