Application for ACMA Membership:

Title.....................Surname........................................................................

Given Names.......................................…………………………..Female/Male

DOB............................…….Country of Birth........................................………

Postal address.........................................................................................……

Home address (optional)........................................................................………

Practice / Hospital address.....................................................................……..

................................................................................................................………

Work Tel..........................………Work Fax........................…..Pager...............

Home Tel.(optional) .......................…….. Home Fax (optional)...................…...

Mobile...............................…... E-Mail...………......….............................………..

Would you like to be included on the ACMA e-Forum?  Yes / No

Would you prefer to receive ACMA correspondence by e-mail?  Yes / No

Qualifications..................................................................................…….........

University................................................................……Year........................

GP / Specialty (list)..........................................…....Intern / RMO / Registrar

Medical Registration No........................….…….QA & CE No. .......................

Admitting Rights……………………………………………………….………….

Previous ACMA member:   No/Yes     Years....……..........................……......

Other Medical Associations.........................................................……............

Languages spoken..................................................................….................

Hobbies/Interests.......................................................................…..............

Spouse name...............................................…..ACMA member? No/Yes

I hereby apply to become an Ordinary member of the Australian Chinese Medical Association Inc and I agree to abide by the rules and regulations of the Association

Signature ....................................................................Date.......................

Nominated by 2 current ACMA members:

1. Name.....................................................................……………….....

Signature...........................................……....................…………..…....

2. Name.......................................................................……….………..

Signature...........................................……........................……………...

Return to:

Australian Chinese Medical Association
    ACMA House
    31 Rembrandt Street
    Carlingford NSW 2118
    Tel (02) 9873 6222 Fax (02) 9872 4777

ASSOCIATION FEES

Entrance fee:
   Ordinary member                                                     $ 75 + $7.50 (GST)
   Intern member                                                           nil

Subscription fee :
    Annual Ordinary Membership (1 Jan - 31 Dec):       $180 + $18 (GST)
    Applying after 20 June (1 July - 31 Dec):                  $90  + $9 (GST)

    Retirees, Spouse Members & New Graduates (1-3 years), Overseas and Interstate Members pay :
                                                                                       50% of above rates 

    Renewal of Annual Subscription is due on 1st January each year.

Life membership fee :

    Life membership is open to Ordinary Members of good standing for two consecutive
    years of membership.

    The current fee is : 
    12 times the annual membership fee (12 x $180):   $2160
                             plus GST :                                    $  216
                                       TOTAL                             $2376

________________________________________________

Enclose cheque payable to the
"Australian Chinese Medical Association Inc."

(Office Use)

Revised: 02/08/2004