Organisation Membership

Application for Organisation Membership

Membership in the Organisation Class of the ACT Medicare Local is limited to:

Peak Body: a body that represents persons eligible to be members of the ACT Medicare Local

Service Providers: a body that provides Primary Health Care in the ACT through employees or contractors, one or more of whom are eligible for membership of the ACT Medicare Local

Consumer Organisations: a body that represents consumers of the Primary Health Care services in the ACT.

Please complete all mandatory fields marked with an *
Organisational Details
Business Name *
Physical Address:
Street *
Suburb/City *
State *	- Please Select - ACT NSW NT QLD SA TAS VIC WA
Post Code *
Mail Address:
	copy from above
Street *
Suburb/City *
State *	- Please Select - ACT NSW NT QLD SA TAS VIC WA
Post Code *
Phone *
Fax
Email
Website
ABN
Health Link Identifier
Number of Full Time Equivalent staff employed:
General Practitioners
Nurse Practitioners
Practice Nurses
Allied Health Professionals
Others
Main Business Purpose *	- Please Select - Peak Body Service Provider Consumer Organisation
Hours of Operation
Monday to Friday
Weekends
Primary Organisation Representative
Title *	- Please Select - Assoc Prof Dr Miss Mr Mrs Ms Prof
First Name *
Last Name *
Position *
Mobile
Email
Membership Consent
By submitting this form, I agree to accept the Constitution of the ACT Medicare Local.
Name *
Health Services Directory
Please do not include my details in the ACT Health Services Directory.