FS 557931
CORRESPONDING MEMBERSHIP APPLICATION FORM
Valid: 1 July 2015 – 30 June 2016
SECTION A: YOUR DETAILS
Have you ever been a member of ASUM?
Name:
Title / First name / Surname
Gender:
M
F
D.O.B.
Editable Document for fast and easy completion
 Yes
 No
Previous Member Number_________
Use this  tick for applicable area/s
__ / __ / __
Home Postal address:
State:
Suburb :
Phone: Work
Fax
( )
( )
Zip/Postcode:
Country
:
Mobile/Cell:
Email:
Name of employer:
Employer’s address:
Suburb :
State :
Zip/Postcode:
Primary Qualifications
Specialist Qualifications
Section B: Corresponding Membership category
 Corresponding Member
Country :
(all rates in Australian Dollars)
A member living outside Australia/New Zealand
Corresponding Dues:
Check which category** you belong to




$ 54
$108
$162
$303
Low income economies
Lower-middle income economies
Upper middle income economies
Higher income economies
** Categories based on World Bank Income found here. Please check here to confirm which category you are from.
SECTION C: SPECIALIST AREAS OF PRACTICE
Use this  tick for applicable area/s
 anaesthetics
 intensive care
 orthopaedic
 rural medicine
 breast
 intra-operative
 paediatrics
 sonography
 cardiology/echocardiography
 musculoskeletal
 physicists
 sports medicine
 critical care
 neonatology
 podiatry
 surgery
 emergency medicine
 nuclear medicine
 physiotherapy
 vascular ultrasound
 fetal
 nursing: ED/midwifery
 radiography
 veterinary
 general
 obstetrics & gynaecology  radiology
Section D: Optional Items
Donation (to research grants and Outreach Programs)
ASUM welcomes additional support for research grants and Outreach Programs covering educational projects and scholarships,
which may be supplementary to its normal expenditure. Such additional donations are acknowledged and gratefully appreciated.
Below you can select an amount and select where the funds are to be directed.
 $25
 $50
 $100
 $200
 $500
Outreach  Australia/New Zealand Rural & Remote
Named Grant  …
Name of Grant:
Page 1 of 2
 Other $
 Asia Pacific  International Disadvantaged Communities
06/15
Australasian Society for Ultrasound in Medicine PO BOX 943, Crows Nest NSW 1585, SYDNEY, AUSTRALIA
P (61 2) 9438 2078 F (61 2) 9438 3686 E asum@asum.com.au W www.asum.com.au
ACN 001 679 161 ABN 64 001 679 161 ISO 9001 certified by BSI under Certificate No. FS 557931
Section E: Payment method
Membership dues:
Donation or Named Grant:
Opt in AJUM hard copy P&P:
$
$
$.
Total to be deducted by ASUM:
$ ________________
 MasterCard
 Visa
Please note Membership and
AJUM payments are tax
deductible.
Donations paid via ASUM are
not tax deductible
 Cheque in $AU, drawn on an Australian Bank
Credit Card No.: Place 4 digits in each of the first 4 boxes
CVV (3 digits on back):
Cardholder’s Name:
Expiry Date:
Cardholder’s Signature:
(electronic signature acceptable)
1
All AU dues and services include GST
Please forward your completed application form, together with a copy of your qualification
by fax: (61 2) 9438 3686, email: membership@asum.com.au or
post: ASUM, PO Box 943, Crows Nest NSW 1585, Australia
Page 2 of 2
06/15
Australasian Society for Ultrasound in Medicine PO BOX 943, Crows Nest NSW 1585, SYDNEY, AUSTRALIA
P (61 2) 9438 2078 F (61 2) 9438 3686 E asum@asum.com.au W www.asum.com.au
ACN 001 679 161 ABN 64 001 679 161 ISO 9001 certified by BSI under Certificate No. FS 557931