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
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