Membership Application Form – Individuals MemberIDPersonal DetailsTitle* Title MrMsMrsMissDrProfAssoc Prof Given Name(s)*Family Name*Date of Birth* DD MM YYYY Place of Birth*Gender*MaleFemaleAre you*Australian AboriginalTorres Strait IslanderAustralian Aboriginal and Torres Strait IslanderNon-IndigenousPreferred Mailing AddressAddress location*WorkHomeOtherAddress* Street Address Address Line 2 Suburb Post Code State/Territory*ACTNSWNTQLDSATASVICWADo you wish to provide an alternate mailing address?YesNoAddress location*WorkHomeOtherAddress* Street Address Address Line 2 Suburb State/Territory Post Code Contact DetailsMobile Phone*Work PhoneHome PhoneFacsimileOtherEmail Address 1 (preferred personal email)* Enter Email Confirm Email Do you wish to provide an alternate email address?*YesNoEmail Address 2 Enter Email Confirm Email Social MediaPlease list any social media links or usernames you would like to share with IAHA (ie - Facebook, Twitter, Instagram, LinkedIn, etc).Preferred Method of Contact*Choose how you prefer to be contacted. You may choose multiple methods of contact. Be sure if you choose a method such as work or home phone that you have provided that number above. Mobile Phone Work Phone Home Phone Email Other Contact MethodIf you have chosen 'other' please provide details about how you prefer to be contactedInternational ApplicantsAre you an Australian citizen?*YesNoCitizenship of what country?*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweWhy do you want to join IAHA?*What can you bring to our Indigenous Australian organisation?*QualificationsPlease choose which best describes you:*I do not currently hold and am not studying formal qualifications.I currently hold a formal qualificationI am studying a formal qualification Please outline all of your qualifications that you hold or are working towards:Please upload current proof of enrolment*Qualification Title*Please state the exact title i.e. Bachelor of Physiotherapy, Masters of Social WorkProfession*What is or what will your Profession be once graduated? ie; Physiotherapist, Occupational TherapistIssuing Institution*(e.g. The University of Queensland)Have you graduated from this course?YesNoYear Commenced(yyyy - e.g. 1995)Current Year of Study(e.g. 3rd Year)Year Graduated (or expected date)(yyyy - e.g. 2015)Do you have accreditation?YesNoWho are you accredited with?Do you have any further qualifications to add?YesNoQualification Title*Please state the exact title i.e. Bachelor of Physiotherapy, Masters of Social WorkProfession*What is or what will your Profession be once graduated? ie; Physiotherapist, Occupational TherapistIssuing Institution*(e.g. The University of Queensland)Have you graduated from this course?YesNoYear Commenced(yyyy - e.g. 1995)Current Year of Study(e.g. 3rd Year)Year Graduated (or expected date)(yyyy - e.g. 2015)Do you have accreditation?YesNoWho are you accredited with?Do you have any more qualifications to add?YesNoQualification Title*Please state the exact title i.e. Bachelor of Physiotherapy, Masters of Social WorkProfession*What is or will your Profession be once graduated? (ie; Physiotherapist, Occupational Therapist)Issuing Institution*(e.g. The University of Queensland)Have you graduated from this course?YesNoYear Commenced(yyyy - e.g. 1995)Current Year of Study(e.g. 3rd Year)Year Graduated (or expected date)(yyyy - e.g. 2015)Do you have accreditation?YesNoWho are you accredited with?Would you like to add another qualification?YesNoQualification Title*Please state the exact title i.e. Bachelor of Physiotherapy, Masters of Social WorkProfession*What is or what will your Profession be once graduated? ie; Physiotherapist, Occupational TherapistIssuing Institution*(e.g. The University of Queensland)Have you graduated from this course?YesNoYear Commenced(yyyy - e.g. 1995)Current Year of Study(e.g. 3rd Year)Year Graduated (or expected date)(yyyy - e.g. 2015)Do you have accreditation?YesNoWho are you accredited with? MentoringAre you interested in having a mentor?YesNoThank you. We will contact you after your application has been processed. Are you interested in being a mentor to other IAHA members?YesNoThank you. We will contact you after your application has been processed. EmploymentCurrent place of workPosition heldPast places of employmentPlease list relevant past employment information Community involvementPlease list relevant community involvement Do you currently work in Aboriginal and/or Torres Strait Islander health?YesNoPlease provide detailsHave you previously worked in Aboriginal and/or Torres Strait Islander health?YesNoPlease provide detailsRepresenting IAHAWould you like to represent IAHA in the future?YesNoWhich area(s) would you like to represent IAHA?Tick all that apply Board of Directors Committees Policy Career Expos/Community Visits Student Representative Committee Other Please specifyDeclarationI hereby declare:I am of Aboriginal and/or Torres Strait Islander descent;*YesNoI am a descendent of:*Please enter the name of your people(s)/countryI identify as an Australian Aboriginal and/or Torres Strait Islander person; and*YesNoI am accepted as such by the community in which I live or have lived*YesNoI am accepted by:*Please enter the name of the community you are accepted byFamily & Cultural Identity*Tell us about your family and your cultural identity (max 1500 characters) DisclaimerPlease tick each box if you agree* I hereby declare that the information provided in this application form is true and accurate to the best of my knowledge; and I hereby declare that I have read and will abide by the IAHA constitution I agree to the use of my personal information for the purposes of IAHA, its secretariat and board, communicating on IAHA matters As a member of Indigenous Allied Health Australia Ltd I agree to contribute the guarantee amount below to the property of that company if it is wound up Note: Subject to the Corporations Act 2001 (Cth), where the company is wound up, a present or past member is liable to contribute up to the guarantee amount to the company’s property: (i) to pay the company’s debts and liabilities and the costs, charges and expenses of the winding up; and (ii) to adjust the rights of contributories among themselves. Subject to the Corporations Act 2001 (Cth), a past member will not need to contribute: (a) in respect of a debt or liability of the company contracted after the person ceased to be a member; (b) if he, she or it was not a member at any time during the year ending on the day of the commencement of the winding up; and (c) unless it appears to the court that the present members are unable to satisfy the contributions that they are liable to make. $ 10.00 (Please do not pay this amount, it is NOT a Membership fee.) Full Name*Electronic SignatureDate* DD MM YYYY
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