MEMBERSHIP APPLICATION FORM
PERSONAL and CONTACT DETAILS
SURNAME
FIRST NAME
PREFIX
GENDER
DATE OF BIRTH
PROFESSIONAL ADDRESS
CURRENT APPOINTMENT/S
PHONE
EMAIL
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☐Female ☐Male
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Work: Click here to enter text.
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Mobile: Click here to enter text.
QUALIFICATIONS / FELLOWSHIPS (including institutions and dates)
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ADVANCED TRAINING (Full (Ordinary) membership applications only)
☐ JSAC (Immunology/Allergy) Year completed: Click here to enter text.
☐ Other - Please specify:
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Type of training:
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Number of years of experience working in Allergy and/or Immunology: Click here to enter text.
Percentage of time currently spent working in Allergy and/or Immunology: Click here to enter text.
REASON/S FOR JOINING ASCIA
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SPONSOR AND REFEREE
SPONSOR NAME (Full ASCIA member): Click here to enter text.
Signed (by sponsor):
COMMENT (if applicable): Click here to enter text.
REFEREE NAME: Click here to enter text.
Phone: Click here to enter text.
(Referee should be a different person to sponsor but does not need to be an ASCIA member)
TYPE OF MEMBERSHIP (please select)
☐ FULL (ORDINARY)
☐ FULL (OVERSEAS)
☐ ASSOCIATE (MEDICAL PRACTITIONERS)
☐ ASSOCIATE (OTHER HEALTH PROFESSIONALS)
☐ASSOCIATE (ADVANCED TRAINEES)
☐ RETIRED (FROM ACTIVE CLINICAL PRACTICE)
2016 ANNUAL FEE (including GST)
$381.00 (attach CV for Full applications)
$247.00
$192.00 (attach CV summary ~ 1-2 pages)
$153.00
$153.00
$124.00
SIGNED (by applicant):
DATE: Click here to enter a date.
Please email completed form to education@allergy.org.au or mail to ASCIA, PO Box 450 Balgowlah NSW 2093.
Payment should NOT be sent with this application.
Once membership has been confirmed by ASCIA Council a Tax Invoice will be sent. Applications for ASCIA membership are
considered periodically by ASCIA Council in accordance with the ASCIA Constitution. Admission to membership is at the
discretion of the ASCIA Council and applications for membership may be declined without providing a reason.
ASCIA is the peak professional body of clinical immunology and allergy specialists in Australia and New Zealand
Website: www.allergy.org.au
ABN: 45 615 521 452
ACN: 608 798 241