Australian Medical Association Membership Form
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1
2AMA Queensland
Membership application form
2016 May Membership Rates
HOW TO APPLY:
3. EMPLOYMENT TYPE/STATUS
• online at
• or by using this application form.
Salaried
Private
Full-time
Are you:
Employer?
Employee?
Position:
Employer:
I hereby apply to be elected a member of the Australian Medical
Association and the Queensland Branch of the Australian Medical
Discipline:
Association, and agree if elected, to observe the principles stated in the
Declaration of Geneva.
Right of private practice:
Yes
No
Private hospital VMO:
Yes
No
1. APPLICATION FOR ADMISSION AS:
(please tick)
Public hospital VMO:
Yes
No
Intern
Principal house officer
International Medical Graduate:
Yes
No
Resident
& Registrar
Junior house officer
Registrar specialty:
4. DECLARATION
Senior house officer
I, (insert name)
General practitioner
Academic
A registered Medical Practitioner am desirous of being and hereby apply
to be elected a Member of the Australian Medical Association and the
Specialty (please specify):
Specialist
Queensland Branch of the Australian Medical Association, AND I AGREE
if elected to observe the principles stated in the Declaration of Geneva.
Are you currently registered with the Medical Board of Australia?
Do you have or have you ever had a suspension, condition/s or other
Yes
No
restriction/s placed on your registration or been subject to criminal
proceedings?
Yes
No
If applicable, under which specialty/specialties are you registered with the
If Yes, please forward an extract of the orders made and any convictions
Medical Board of Australia?
recorded to the General Manager of Membership, Holly Bretherton
.au for further review with your application for
2. CONTACT DETAILS:
(Please print BLOCK LETTERS in blue/black ink)
membership, or call Holly to discuss on (07) 3872 2248.
Full name:
Signature:
Date:
Gender:
Male
Female
Date of birth:
/
/
Your membership with AMA Queensland also includes membership with the
Australian Salaried Medical Officers Federation Queensland (ASMOFQ) and
Postal/home address:
additionally it’s Federal counterpart the Queensland Branch of the Australian
Salaried Medical Officers Federation for no extra fee.
As a salaried doctor, I do not wish to be an ASMOFQ member.
Principal practice name:
5. REGISTER TO VOTE
Register your vote. Members have the opportunity to vote for craft group and
Principal practice address:
area representatives in the annual Branch, and Federal Council elections of
AMA. To register for vote please complete the Craft Group section below.
Preferred Mailing/Geographic Area: (Please tick)
Suburb:
State:
Postcode:
Greater Brisbane 4000-4199, 4300-4349, 4500-4549
Practice phone:
Capricorn Coast 4676-4798
Gold Coast Area 4200-4299
Mobile:
After hours phone:
North Coast Area 4550-4601, 4619-4675
North Area 4799-4850
Practice fax:
Pager number:
Far North Area 4851-4899
Email:
Downs and West Area 4350-4499, 4602-4618
AMA Queensland Craft Group: (Please tick)
Graduation year:
Institution:
Part-time Medical Practitoner
General Practitioner
Doctor in Training
Qualification/s: (including College fellowships)
Specialist
Medical Student
Full-time Salaried Medical Officer
Please indicate if your spouse is a medical practitioner:
Yes
No
Federal AMA Craft Group: (Please tick)
Doctors-in-training
If yes, please name:
Obstetrician Gynaecologist
General Practitioner
Pathologist
Salaried Doctor
Please indicate if you are proficient in a language/s other than English:
Dermatologist
Paediatrician
Radiologist
Psychiatrist
Emergency Physician
Opthalmologist
How do you wish to receive Doctor Q magazine?:
Online
Post
Anaesthetist
Surgeon
Orthopaedic Surgeon
How do you wish to receive the Annual Report?:
Online
Post
Physician
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