AMA Queensland
Membership application form
HOW TO APPLY:
3. EMPLOYMENT TYPE/STATUS
• o nline at www.amaq.com.au
• or by using this application form.
Salaried
I hereby apply to be elected a member of the Australian Medical
Association and the Queensland Branch of the Australian Medical
Association, and agree if elected, to observe the principles stated in the
Declaration of Geneva.
1. APPLICATION FOR ADMISSION AS: (please tick)
Resident
& Registrar
Intern
Principal house officer
Junior house officer
Registrar specialty:
Employer?
Employee?
Employer:
Discipline:
Right of private practice:
Yes
No
Private hospital VMO:
Yes
No
Public hospital VMO:
Yes
No
International Medical Graduate:
Yes
No
A registered Medical Practitioner am desirous of being and hereby apply
to be elected a Member of the Australian Medical Association and the
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?
Yes
Position:
Are you:
I, (insert name) Academic
Specialty (please specify):
Specialist
Full-time
4. DECLARATION
Senior house officer
General practitioner
Private
No
If applicable, under which specialty/specialties are you registered with the
Do you have or have you ever had a suspension, condition/s or other
restriction/s placed on your registration or been subject to criminal
Yes
No
proceedings?
2. CONTACT DETAILS: (Please print BLOCK LETTERS in blue/black ink)
If Yes, please forward an extract of the orders made and any convictions
recorded to the General Manager of Membership, Holly Bretherton
[email protected] for further review with your application for
membership, or call Holly to discuss on (07) 3872 2248.
Full name:
Signature:
Medical Board of Australia?
Gender:
Male
Female
Date of birth:
/
/
Date:
Your membership with AMA Queensland also includes membership with the
Australian Salaried Medical Officers Federation Queensland (ASMOFQ) and
additionally it’s Federal counterpart the Queensland Branch of the Australian
Salaried Medical Officers Federation for no extra fee.
Postal/home address:
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
area representatives in the annual Branch, and Federal Council elections of
AMA. To register for vote please complete the Craft Group section below.
Principal practice address:
Suburb:
State:
Preferred Mailing/Geographic Area: (Please tick)
Postcode:
Greater Brisbane 4000-4199, 4300-4349, 4500-4549
Capricorn Coast 4676-4798
Gold Coast Area 4200-4299
North Coast Area 4550-4601, 4619-4675
North Area 4799-4850
Far North Area 4851-4899
Downs and West Area 4350-4499, 4602-4618
Practice phone:
Mobile:
After hours phone:
Practice fax:
Pager number:
Email:
Graduation year:
AMA Queensland Craft Group: (Please tick)
Institution:
General Practitioner
Specialist
Full-time Salaried Medical Officer
Qualification/s: (including College fellowships)
Please indicate if your spouse is a medical practitioner:
Yes
No
If yes, please name:
Please indicate if you are proficient in a language/s other than English:
How do you wish to receive Doctor Q magazine?:
Online
Post
How do you wish to receive the Annual Report?:
Online
Post
Federal AMA Craft Group: (Please tick)
General Practitioner
Salaried Doctor
Paediatrician
Psychiatrist
Opthalmologist
Surgeon
Physician
Part-time Medical Practitoner
Doctor in Training
Medical Student
Doctors-in-training
Obstetrician Gynaecologist
Pathologist
Dermatologist
Radiologist
Emergency Physician
Anaesthetist
Orthopaedic Surgeon
7. PAYMENT DETAILS: (Payment is accepted by cheque, credit card or direct debit)
MAY 2015 MEMBERSHIP RATES
Membership category
Single
Joint*
GP - Private Practice (FPP1)
$944.00
$776.00
Membership category: (refer to table on the left)
SPEC - Private Practice (FPS1)
$944.00
$776.00
Salaried Medical Officer (FSS1)
$944.00
$776.00
Part Time 0-10hrs P/Week (FPT1)
$232.00
$184.00
Part Time 11-20hrs P/Week (FPT2)
$512.00
$400.00
Part Time 21-30hrs P/Week (FPT3)
$680.00
$544.00
7a. PAYMENT BY CREDIT CARD:
Intern Standard (F1Y1)
$304.00
$240.00
Please charge my credit card:
Junior House Officer (F2Y1)
$352.00
$280.00
Senior House Officer (F3Y1)
$408.00
$328.00
Principle House Officer (F4Y1)
$496.00
$392.00
Registrar (F5Y1)
$584.00
$464.00
Acad/Postgraduate (FAA1)
$552.00
$440.00
Overseas incl unattached (FBB1)
$496.00
$392.00
Retired (FRR1)
$176.00
$144.00
Over Seventy Practicing (FVV1)
$448.00
$360.00
Parental Leave (ML)
$224.00
$176.00
*Joint rates apply to members with a spouse/partner who is also an AMA Member.
CONCESSIONS AVAILABLE (CONDITIONS APPLY)
International Medical Graduate
1st year practising in Australia
20% discount off the above fees
International Medical Graduate
2nd year practising in Australia
10% discount off the above fees
A one-off 50% exam
concession is available for
Junior doctors that sit an exam
Please discuss with AMA Queensland staff
to access this reduction
Promotional Code (if applicable):
Subscription amount $
Select ONE payment method from below:
Visa
Payment :
MasterCard
In full
Quarterly
Amex
Monthly
Card number:
Expiry date:
/
Amount $
I authorise and request AMA Queensland to debit the above nominated
credit card upon receipt of this authorisation and thereafter as nominated
above (monthly, quarterly or annually). I acknowledge this is a perpetual
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.
Cardholder’s name:
Signature:
7b. PAYMENT BY DIRECT DEBIT:
T o download a direct debit form go to www.amaq.com.au/directdebit
or contact the membership department on 07 3872 2222 or
[email protected].
7c. PAYMENT CHEQUE/MONEY ORDER:
I have enclosed a cheque/money order payable to AMA Queensland
6. MEMBER GET A MEMBER PROGRAM
REDUCTION
AMA Queensland’s Member Get a Member Program offers
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
member you introduce.
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!
8. WHAT WOULD YOU LIKE FROM YOUR MEMBERSHIP:
Why are you joining AMA Queensland: (Please tick)
Belonging to the peak medical professional body
Lobbying health policy areas
Name of member who referred you:
Professional resources and training
Name of colleague you are referring:
Workplace and industrial relations support and advice
and receive a discount
on your membership rates
Refer 1 member
Refer 2 members
25% discount
on your membership
50% discount
on your membership
Refer 3 members
Refer 4 members
75% discount
on your membership
No membership fee
for one year
9. WHAT HAPPENS NEXT
Upon receipt of your application, your payment will be processed. Payment of
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
receive a membership pack including a membership card and certificate. Any
application not approved by the board will be notified in due course and any
subscription paid will be refunded to you.
NB: For new members who wish to access the AMA Volkswagen offer for the
purchase of a new vehicle, please note you must have at least three months
membership before you can access the advertised discounts.
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 www.amaq.com.au/membership
AMAQ9612
Refer a member