APPLICATION FOR MEMBERSHIP Phone:
(Please use block letters, print clearly) Fax:
E-mail: katrinalwatson

ALL CORRESPONDENCE TO
Dr Katrina Watson
Assistant Federal Secretary AMAC
PO Box 252
LEOPOLD VIC 3224

NAME (in block letters)

SURNAME....................................................................................................……….....................

GIVEN NAMES......................................................................................………..........................

DATE OF BIRTH..............................…….....................................................................................

ADDRESS (Surgery) ...............................................................………..............................................................................

................................................................................... Post Code...............................…............

Telephone..........................……..........….............. Fax...............................……............................

E-mail ..................................................................................……….........………………………..

(Home) ........................................................................................……….....................................................

.................................................................................. Post Code..............….............................

Telephone........................................................………....................................................................

MAILING ADDRESS .........................................................................………....................................................................

.................................................................................. Post Code....................................……...

MEDICAL DEGREES ......................................……….......................................................................................................

Place & Date ..........................................………...................................................................................................

ACUPUNCTURE COURSES .................................………............................................................................................................

Place & Date ...................................………..........................................................................................................

MEMBERSHIP OF OTHER

PROFESSIONAL BODIES ............................................……….................................................................................................

NOMINATED BY MEMBER: Dr..........................…...................................SIGNED........................……...................................

SECONDED BY MEMBER: Dr..........................…...................................SIGNED............……...............................................

APPLICANT'S SIGNATURE ...........................................................…….....................DATE...............................…..................

PHOTOCOPIES OF THE FOLLOWING MUST ACCOMPANY THIS APPLICATION BEFORE IT CAN BE PROCESSED:

1. Current Practicing Certificate from your State Medical Board

• Certificate / Diploma of Acupuncture Course(s) attended

• Your payment for subscription & joining fee - see tax invoice for payment options 1 Feb 2004

_______________________________________________________________________________________________________

FOR OFFICE USE ONLY

DATE OF APPPROVAL: SIGNATURE OF ACCREDITATION OFFICER:

TAX INVOICE

Name. _________________________________________________

Address ____________________________________________

____________________________________________

Tel.___________________ Fax.__________________

E-Mail ______________________________________

Please fill in the above, for the Treasurer's records.

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1 July - 30 June (12 months)
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$100.00
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$286.00

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Expiry Date.................................................

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Please note that you may make Credit Card payment by phone or fax or mail.

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