Australian Medical Association Membership Form (Page 2 of 2) in pdf

2016 MAY MEMBERSHIP RATES

7. PAYMENT DETAILS

(Payment is accepted by cheque, credit card or direct debit)

Direct Debit

Promotional Code (if applicable):

Membership category

Single

Monthly

Membership category: (refer to table on the left)

GP - Private Practice (FPP1)

$967.33

$120.92

SPEC - Private Practice (FPS1)

$967.33

$120.92

Subscription amount $

Salaried Medical Officer (FSS1)

$967.33

$120.92

Part Time 0-10hrs P/Week (FPT1)

$238.00

$29.75

Select ONE payment method from below:

Part Time 11-20hrs P/Week (FPT2)

$525.33

$65.67

7a. PAYMENT BY CREDIT CARD:

Part Time 21-30hrs P/Week (FPT3)

$697.33

$87.17

Please charge my credit card:

Visa

MasterCard

Amex

Intern Standard (F1Y1)

$301.33

$37.67

Junior House Officer (F2Y1)

$352.00

$44.00

Payment :

In full

Quarterly

Monthly

Senior House Officer (F3Y1)

$408.00

$51.00

Card number:

Principle House Officer (F4Y1)

$496.00

$62.00

Registrar (F5Y1)

$584.00

$73.00

Acad/Postgraduate (FAA1)

$566.00

$70.75

Expiry date:

Amount $

Overseas incl unattached (FBB1)

$508.67

$63.58

Retired (FRR1)

$180.67

$22.58

I authorise and request AMA Queensland to debit the above nominated

credit card upon receipt of this authorisation and thereafter as nominated

Over Seventy Practicing (FVV1)

$459.33

$57.42

above (monthly, quarterly or annually). I acknowledge this is a perpetual

Parental Leave (ML)

$229.33

$28.67

authorisation and will remain in force until cancelled in writing. In the event

that my application for membership is not approved AMA Queensland will

refund any subscription amount paid.

*Membership valid until 31/12/2016

*Joint rates apply to members with a spouse/partner who is also an AMA Member.

Cardholder’s name:

CONCESSIONS AVAILABLE (CONDITIONS APPLY)

Signature:

International Medical Graduate

20% discount off the above fees

1st year practising in Australia

7b. PAYMENT BY DIRECT DEBIT:

International Medical Graduate

10% discount off the above fees

To download a direct debit form go to

2nd year practising in Australia

or contact the membership department on 07 3872 2222 or

A one-off 50% exam

Please discuss with AMA Queensland staff

.au.

concession is available for

to access this reduction

7c. PAYMENT CHEQUE/MONEY ORDER:

Junior doctors that sit an exam

I have enclosed a cheque/money order payable to AMA Queensland

6. MEMBER GET A MEMBER PROGRAM

8. WHAT WOULD YOU LIKE FROM YOUR MEMBERSHIP:

AMA Queensland’s Member Get a Member Program offers

Why are you joining AMA Queensland: (Please tick)

an outstanding financial incentive for existing members to

introduce new doctors to join AMA Queensland. Receive

a 25% discount on next year’s membership for each new

Belonging to the peak medical professional body

REDUCTION

member you introduce.

Lobbying health policy areas

Have you been referred by a member or would you like to refer a colleague?

Let us know who so we can apply the discount!

Professional resources and training

Name of member who referred you:

Name of colleague you are referring:

Workplace and industrial relations support and advice

REFER A MEMBER

9. WHAT HAPPENS NEXT

AND RECEIVE A DISCOUNT

Upon receipt of your application, your payment will be processed. Payment of

ON YOUR MEMBERSHIP RATES

the subscription amount is accepted subject to approval of your application

for membership by the Board of AMA Queensland. If your membership

application is approved by the board, you will then be notified by letter. Upon

Board approval, you are entitled to member services and benefits. You will then

Refer 1 member

Refer 2 members

receive a membership pack including a membership card and certificate. Any

25% discount

50% discount

application not approved by the board will be notified in due course and any

on your membership

subscription paid will be refunded to you.

NB: For new members who wish to access the AMA Volkswagen offer for the

Refer 3 members

Refer 4 members

purchase of a new vehicle, please note you must have at least three months

membership before you can access the advertised discounts.

75% discount

No membership fee

on your membership

for one year

Return complete form to:

Membership Department, AMA Queensland, Reply Paid 123 Red Hill

(Postage is free by marking Reply Paid on any plain envelope) or fax all pages

to (07) 3856 4727 or APPLY ONLINE at

Australian Medical Association Membership Form Page 2

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