NEW MEMBER APPLICATION

To join online, please complete the New Member Application Details Form below.

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	Personal Details Please note: All fields marked with (*) are required. This form will not be accepted without these fields being completed.
Title (*)	Please SelectMrMrsMsDrMiss Invalid Input
First Name (*)	Please type your first name
Surname (*)	Please type your surname.
Date of Birth (*)	Please type your D.O.B.
Gender	FemaleMale Invalid Input
Home Phone Number (*)	Invalid Input
Personal Mobile	Invalid Input
Home Address (*)	Please type your street address
Home Address 2	Invalid Input
Home Suburb (*)	Please type your suburb.
State (*)	Please SelectACTNSWVICSAWANTQLDTAS Please tell us your state.
Postcode (*)	Please type your postcode.
Personal Email Address (*)	Invalid Input
	Home Postal Details If your home mailing details are different to your home street address, please complete the following:
Mailing Address	Invalid Input
Mailing Address 2	Invalid Input
Mailing Suburb	Invalid Input
Mailing State	NSWQLDSAWAACTNTVIC Invalid Input
Mailing Postcode	Invalid Input
	Work Details All fields required.
Employer (*)	Invalid Input
Work Phone (*)	Please type your phone number.
Work Mobile Phone	Invalid Input
Work Address (*)	Invalid Input
Work Suburb (*)	Invalid Input
State (*)	Please SelectACTNSWVICSAWANTQLDTAS Please tell us your state.
Postcode (*)	Invalid Input
Work E-mail (*)	Please type your email address.
	Preferred Contact Details All fields required.
Preferred Contact (*)	HomeWork
	Professional Details
Have you ever been a member of the ACMHN?	Please SelectYesNo
Member Number	Do you know your member number?
Nurses Registration Number (*)	Invalid Input
Are you interested in being a member of the Consultation Liaison Special Interest Group?	Please SelectYesNo
Are you interested in being a member of the Private Practice Special Interest Group?	Please SelectYesNo
Primary practice setting	Please SelectHospitalCommunityOther (specify below): Invalid Input
Other (please specify)	Invalid Input
Place of practice:	Public Health ServicePrivate Health ServiceEducation SectorNGONursing AgencyOther (specify below); Invalid Input
Other (please specify)	Invalid Input
Regional location	Please SelectInner CityMetropolitanRegionalRuralRemoteOther (specify below); Invalid Input
Other (please specify)	Invalid Input
Primary work focus (required) (*)	Please SelectManagement/AdministrationClinicalEducationResearchPolicyOther (specify below); Please stste your primary work focus.
Other (please specify)	Invalid Input
Current fields of practice: Click to view examples	Invalid Input
Primary Position Click to view examples	Invalid Input
Academic & professional qualifications	Qualification: Institution: Year Awarded Invalid Input
Research interests & experience	Invalid Input
	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.
Help us to avoid spam - please enter these four numbers	Please enter the numbers above correctly