Personal Information
Prefix
Prefix
Prefix
Prefix
Prefix
First Name
Surname
Date of Birth
Organisation Name
Contact Details
Work Phone
Mobile Phone
Email Address
Secondary Email
Primary Address
Organisation Name
Home Address
Address 1
Suburb / Town
Postcode
State
Country
Are you a GP in training?
Primary Medical Qualifications (Please provide full name of any degree or diploma, institution and year of graduation)
Primary Medical
Undergraduate qualifications (Please provide full name of any degree or diploma, institution and year of graduation)
Undergraduate qualifications
Postgraduate qualifications (If applicable - please provide full name of any degree or diploma, institution and year of graduation)
Postgraduate qualifications
Registration Body
Registration Body
RACGP & ACRRM Number (if applicable)
Registration Body
AHPRA Number
AHPRA Number
Membership/Fellowship of professional body (Please provide name of body, country, qualification, month & year awarded)
Membership/Fellowship
Practice Setting
Clinical interests
Practice Type
Do you have any conditions with respect to your professional registration? (If yes, please detail)
Membership/Fellowship
Approximate hours worked (including hours spent in psychological medicine)
Membership/Fellowship
Languages spoken
Membership/Fellowship
I am interested in participating in the following Society activities:
Member Profile for Directory (max 150 words)
Membership/Fellowship
Directory Image (max size 1 Mb)
File Upload
Do you have Prior Training in FPS Level 1 or 2?
Prior Training in FPS Level 1 or 2 - please advise level held, year completed and training provider (if not undertaken, please write 'N/A')
Membership/Fellowship
How did you hear about ASPM?
If referred by existing member, please list full name and contact details
Membership/Fellowship
What is your Facebook name? (We will invite you to the closed Facebook Group ASPM Members Connect once your membership is finalised)
What is your Facebook name? (We will invite you to the closed Facebook Group ASPM Members Connect once your membership is finalised)
Please give us an insight into how you align with ASPM’s core vision to foster whole person care through education, connection, and advocacy
Please give us an insight into how you align with ASPM’s core vision to foster whole person care through education, connection, and advocacy
Payment
Fees Due $440.00 (inc GST)
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Payment Method
Payment Method
Name on Card
Card Number
Card Expiry
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