AMRIA

Personal Details

Title

Last Name

First Name

Date of Birth

Address

Residential address* (PO Box not acceptable)

Suburb

STATE

Post Code

Email

Phone Number

Professional History

Your CV*, detailing your qualifications and experience (summary of the last 10 years) Transcripts* of your academic qualifications (must be certified)

Select a file

Other Professional Association membership(s)

Referees

First Referee's Name (include title)

First Referees's Mobile

First Referee' Email

First Referee's Organisation

Second Referee's Name (include title)

Second Referee's Mobile

Second Referee's Email

Second Referee's Organisation

Membership Type

Application can be for one of three types:
1.Student Member (full time students) – free of application fee
2.Student Member (part time students) – $50 application fee
3.Ordinary Member (select class below) – $100 application fee

Select the class of membership applied for (refer to Appendix B):

Medical MRI Specialist Medical MRI Scientist Speciality MRI Practitioner Allied Health MRI Practitioner Academic and Research Technical/ Engineering/ Management Medical Requestors Other

If Other please specify

Declaration and signature

By signing this declaration, I acknowledge that:
•I have read the Australian Privacy Principles and I understand and consent to how Australian MedialResonance Imaging Association will use my personal information.
•The information I have provided was true and accurate at the time of completion.

Full Name

Today's date