NEW MEMBER APPLICATION

 

To join online, please complete the New Member Application Details Form below. Once you have completed the form, press Continue to proceed to our secure Online Payments Page.

Membership Application

Personal Details

Please note: All fields marked with (*) are required. This form will not be accepted without these fields being completed.
Title(*)
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First Name(*)
Please type your first name
Surname(*)
Please type your surname.
Date of Birth(*)
Please type your D.O.B.
Gender
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Home Phone Number(*)
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Personal Mobile
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Home Address(*)
Please type your street address
Home Address 2
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Home Suburb(*)
Please type your suburb.
State(*)
Please tell us your state.
Postcode(*)
Please type your postcode.

Home Postal Details

If your home mailing details are different to your home street address, please complete the following:
Mailing Address
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Mailing Address 2
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Mailing Suburb
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Mailing State
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Mailing Postcode
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Work Details

All fields required.
Employer(*)
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Work Phone(*)
Please type your phone number.
Work Mobile Phone
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Work Address(*)
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Work Suburb(*)
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State(*)
Please tell us your state.
Postcode(*)
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Work E-mail(*)
Please type your email address.

Preferred Contact Details

All fields required.
Preferred Contact(*)

Professional Details

Have you ever been a member of the ACMHN?
Member Number
Do you know your member number?
Nurses Registration Number(*)
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Are you interested in being a member of the Primary Mental Health Care Special Interest Group?
Are you interested in being a member of the Consultation Liaison Special Interest Group?
Are you interested in being a member of the Perinatal & Infant Mental Health Special Interest Group?
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Are you interested in being a member of the Aboriginal & Torres Strait Islander Special Interest Group?
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Are you interested in being a member of the Clinical Supervision Special Interest Group?
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Are you interested in being a member of the Older Adults Special Interest Group?
Primary practice setting
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Other (please specify)
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Place of practice:
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Other (please specify)
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Regional location
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Other (please specify)
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Primary work focus
(required)
(*)
Please stste your primary work focus.
Other (please specify)
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Current fields of practice: Click to view examples
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Primary Position Click to view examples
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Academic & professional qualifications
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Research interests & experience
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How Did You Hear About Us?(*)
Please let us know how you heard about us
Other (please specify)
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Before you submit this application - please do ensure that you have filled out all the fields above marked with this symbol - (*). Any incorrect fields will be highlighted in red after you hit submit and you will have to re-enter your data. Finally as part of our anti-spam process - please ensure you fill out the four numbers listed below correctly prior to submission.
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