Membership Application

Membership application for Australian psychiatrists and Australian psychiatric trainees

Membership Information

You have selected the Member membership level.

The price for membership is $297.00 now.

Membership expires on December 31, 2024.

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Email Address

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Title

First Name

Last Name

Address

Suburb

State

Postcode

Phone

Mobile

Specialty

Professional Qualifications

Principal hospitals I am accredited to

Professional medical organisations I belong to

You may use the names of 2 referees being Australian registered medical practitioners in good standing who can verify your information if required.

Referee

Referee address

Contact email address

Second Referee

Second referee address

Contact email address

Card Number

Expiration Date

CVC

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