MEMBERSHIP APPLICATION FORM
2014
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Thank you for your application. Please complete the following for membership.
Surname:
_______________________________
Employer / Organisation:
Phone:
First Names:
________________________________________
_____________________________________________________________________________________
__________________
Mobile:
__________________
E-mail:
________________________________
Please select if you wish to receive email notices and updates from ATANZ
Qualifications
Profession / Position Held:
Qualifications:
____________________________________________________________________________________
_____________________________________________________________________________________________
Professional Membership or Registration No (e.g. OT Board, SLT Membership):
MOH Accreditation (if held: CAT-1; CAT-2):
_________________________________________
______________________________________________________________________
2014 Membership Type
Practitioner Membership
$90
Associate Membership*
$90
Student Member
$45
* Please note that Associate Membership is non-voting.
Payment options
Request Invoice
VISA
MasterCard
Cheque
(Please make this payable to ‘ATANZ’)

Credit Card Details:
Name:
___________________
Number:
___________________________
Expiry Date:
___________________
Invoice / Receipt – please select either of the following and provide address details:
I am paying for membership independently or are making the initial payment and claiming it back from my employer.
Home postal address:
__________________________________________________________________________________
Membership is being paid directly by my employer or other party.
Organisation postal address:
Contact person or attention to:
_____________________________________________________________________________
______________________________
E-mail:
________________________________
A certificate of membership and tax receipt will be provided once payment is processed. Costs are inclusive of GST.
Please submit application or queries to admin@atanz.org.nz or post to ATANZ C/- TalkLink Trust, PO Box 44053, Pt Chevalier, Auckland 1246
Copies of the ATANZ Trust Deed are available from www.atanz.org.nz

For the purposes of ATANZ, assistive technology is defined as “any item, piece of equipment or product system whether acquired commercially
off the shelf, modified or customised that is used to increase or improve functional capabilities of people with disabilities” (Cook and Hussey)

An Assistive Technology Practitioner is defined as one or more of the following:
o An Accredited Assessor under the Ministry of Health scheme
o An ACC approved Assistive Technology assessor and/or provider
o A member of a related professional body e.g. speech-language therapist, occupational therapist, teacher, psychologist working or
seeking to work in Assistive Technology service provision.
o Managers of services who are actively involved in the provision or development of direct services in Assistive Technology.

An Associate Member:
o Individuals who market/supply Assistive Technology equipment/solutions.
o Families and Assistive Technology users
These criteria are a guide only. The Trustees reserve the right to evaluate appropriate membership on a case by case basis.
ASSISTIVE TECHNOLOGY ALLIANCE NEW ZEALAND TRUST INCORPORATED
ATANZ Membership Form: 26Feb2014