Membership Fee The cost of the membership is $120. The subscription will be valid until June 2016.

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1 Restaurant/Cafe Membership Application Form of Coeliac Victoria and Tasmania ABN: PO Box 89 Holmesglen Vic 3148 Fax: Coeliac Victoria and Tasmania is committed to changing the lives of people requiring a gluten free diet through awareness, detection, management and the search for a cure. Promoting health, wellbeing and information amongst the medical fraternity and the food industry is a vital part of this commitment. We welcome your membership and look forward to our association together. People with coeliac disease remain sensitive to gluten throughout their life, so in this sense they are never cured. However in most instances a gluten free diet does allow the condition to be managed effectively and coeliacs can live a healthy, active and pain-free life. Membership Fee The cost of the membership is $120. The subscription will be valid until June You can improve your business profile by joining as a Professional Member. Membership represents an excellent opportunity to promote your business to this valuable consumer group and benefit from a close professional association with Coeliac Victoria & Tasmania. This level of membership is especially tailored for the gluten free catering industry. Your clients will feel more at ease knowing you have joined CVT as you will have access to the latest, up to date information to cater to their needs. Professional Membership includes: Coeliac Australia Ingredient List - a comprehensive listing of common food ingredients which highlights suitability of gluten free ingredients Gluten free catering fact sheets Inclusion in two places on our website restaurant listing, highlighted by a Gold Star and your logo/picture (if supplied). Laminated Sign to display on your counter/wall Transparent stickers to display on your shop window, highlighting your membership status Professional Membership Subscription $

2 Advertising with Coeliac Victoria Coeliac Victoria offers a range of advertising opportunities to suit all gluten free food manufacturers and retailers.. Advertisements or inserts in Coeliac Victoria newsletter, The Inside Story to over 5,500 members Advertisement in our e-news electronic newsletter sent to over 4,000 members If you would like to discuss any further information contact: Jackie Gale Administration Officer Coeliac Victoria and Tasmania 9-11 Barlyn Road Mt Waverley or PO Box 89, Holmesglen 3148 P: F: E: victasadmin@coeliac.org.au Saturday 10th and Sunday 11th October 2015 Melbourne Exhibition Centre Come along and see all that s new in the world of gluten free dining, catering, retail and wholesale! 9-11 Barlyn Road Mt Waverley 3149 PO Box 89, Holmesglen Vic 3148 Phone: Fax: VicTas@coeliac.org.au

3 Application Form Page 1 Restaurant/Cafe Name Contact Name Position Address Please return full page Phone Website Opening Hours Cuisine Large Groups Yes/No Licensed/BYO Payment Details Please find enclosed cheque/money order for Or Credit card: MasterCard Visa Authorised Amount $ Card Number: Expiry Date / CCV No. (last 3 digits on the signature panel) Cardholder s Name: Cardholder s Signature: I hereby apply to become a member of Coeliac Victoria and Tasmania. (Signature) (Date)

4 Please return full page Questionnaire Page 2 To be granted a Professional Membership, the following questions must be completed to satisfaction of CVT. 1. Do you undertake to provide gluten free food or gluten free meal options in your restaurant/café for the subscription period? Yes/ No 2. Are you and your staff aware of issues of cross contamination in relation to gluten free foods? Yes / No 3. How will patrons be able to establish which items are gluten free on your menu? Foods on menu/display are noted/labelled as gluten free Staff are educated as to what items are gluten free and are able to confidently answer customer s inquiries Gluten free meals/foods are prepared on request without prior notice Gluten free meals/foods are prepared on request provided prior notice is given 4. What practices do you use in your kitchen to manage cross contamination issues? 5. How will you ensure that current and new staff are provided with appropriate training and understanding of gluten free food management? 6. I understand that all products marked gluten free DO NOT consist of any ingredients containing gluten and are not exposed to cross-contamination. Yes/No 7. I understand that oats are not gluten free in Australia, even if marked wheat free or contamination free, and are not suitable for someone with coeliac disease. Yes/No Privacy: The information collected in the application form is for data collection only and individual names and details will not be divulged to any organization or body without your permission (the only exception is to the companies who package material for Coeliac Victoria and Tasmania and with whom we have a confidentiality agreement). The information collected will assist us in funding applications, encouraging medical research, in discussions with food manufacturers and government agencies and in establishing links with similar organisations.

5 Terms & Conditions Page 3 Conditions: Coeliac Victoria and Tasmania has the right to refuse to grant Professional Membership if the applicant does not answer the questions to the satisfaction of Coeliac Victoria and Tasmania. The Professional Membership fee is not processed until an applicant is approved. Professional Membership is granted by Coeliac Victoria and Tasmania for the subscription period. At the end of the subscription period, existing Professional Members must complete a renewal application form. If the application is successful, Professional Membership will be granted for a further 12 month period, a new sticker and certificate will be issued and a further fee is payable. Coeliac Victoria and Tasmania Inc reserves the right to withdraw Professional Membership at any time if they receive two or more complaints from patrons that the provision of gluten free food by the Professional Member is not satisfactorily managed or is no longer available. If a first complaint is received, Coeliac Victoria and Tasmania Inc may contact the restaurant/café to establish if there is an issue regarding the service provided in relation to gluten free food. If a second complaint is received, Coeliac Victoria and Tasmania may withdraw the restaurant/café's Professional Membership. Professional Membership signs and stickers are issued to the contact person/manager nominated on the application form. Professional Membership lapses if there is a change in restaurant/café management or ownership. Coeliac Victoria and Tasmania Inc reserves the right to withdraw the Professional Membership of a restaurant/café if Coeliac Victoria and Tasmania Inc is satisfied that the restaurant/café no longer provides gluten free food, or if Coeliac Victoria and Tasmania Inc discovers by any means that any information provided on this application form is incorrect. If Professional Membership is withdrawn or lapses, the restaurant/café must remove both the Professional Membership sign and sticker from display and destroy them immediately. Coeliac Victoria and Tasmania Inc will remove all references to the restaurant/café from Coeliac Victoria and Tasmania Inc website. A Professional Member is only permitted to use Coeliac Victoria and Tasmania Inc affiliation and logo by displaying the Professional Membership sticker and Professional Membership sign supplied. Any other use of Coeliac Victoria and Tasmania Inc's registered name, logo or affiliation for marketing, advertising or promotional purposes is prohibited and Professional Membership will be withdrawn. A Professional Member must comply with directions from Coeliac Victoria and Tasmania Inc regarding the use of the term Professional Member and use of Coeliac Victoria and Tasmania Inc's logo and registered name. A Professional Member must notify Coeliac Victoria and Tasmania Inc of any changes to the information provided on this application form. Coeliac Victoria and Tasmania Inc will rely on the information provided by each Professional Member and will not conduct independent verifications. Please return full page Please sign that you will abide by the above Terms and Conditions: Name: Signature: Please print in BLOCK LETTERS Privacy and Collection Statement Coeliac Victoria and Tasmania Inc collects and uses your personal information as a requirement of membership and statistical information for such things as funding and grants. Our Privacy Statement advises you how we usually collect and disclose your personal information and how you can ask for access to it. Our Privacy Statement is available on or by phoning (03)