Individual Membership for GPs

APPLICATION FOR INDIVIDUAL MEMBERSHIP GP CLASS

Please complete all mandatory fields marked with an *

Personal Details

Title *

First Name *

Surname *

Gender *

Preferred Email *

Preferred Mobile

Preferred Contact Address *

Business Address
(For inclusion in ACT Health Services Directory)

Organisation

Street

Suburb/City

State

PostCode

Phone

Fax

Personal Address
(For office use only – not for publication)

Street

Suburb/City

State

Post Code

Phone

Fax

Clinical Practice

Practice / Organisation *

Average Hours per Week

Practice / Organisation

Average Hours per Week

Practice / Organisation

Average Hours per Week

Practice / Organisation

Average Hours per Week

RACCGP #

ACRRM #

Special Interests (please tick relevant fields)

Adolescent - Youth HealthAged CareAlcohol/Other Drugs
Aviation MedicineDermatologyDiabetes
Diving MedicineHealth PromotionIndigenous Health
Medical EducationMen’s HealthMental Health
Minor SurgeryObstetricsOccupational Medicine
Pain ManagementPalliative CarePublic Health
ResearchRespiratory MedicineSexual Health
Sports MedicineTravel MedicineWomen’s Health

Other

Languages Spoken

Membership Consent

By submitting this application, I agree to accept the Constitution of the ACT Medicare Local.

Health Services Directory
(Personal details will not be provided)

Please do not include my details in the ACT Health Services Directory.