ASMIRT CPD Subscriber Application Form

Subscription Type

CPD Subscriber - Individual

For CPD Subscribers who are paying for the CPD Subscription yearly.

Enter Code

Code is invalid

Subscription Period

Subscription Fee

AUD${{ cost }}

Admin Fee

AUD${{ selectedMembershipType['JoiningFee'] }}

Title: Mr/Mrs/Miss/Other This field is required.

Other Title This field is required.

First Name This field is required.

Middle Name (Optional)

Last Name This field is required.

Maiden Name (If applicable)

Date Of Birth This field is required.

Postal Address This field is required.

Town/ Suburb This field is required.

State/Territory This field is required.

Other State This field is required.

Postcode This field is required.

Country This field is required.

Tel (Home) This field is required.

Tel (Mobile) This field is required.

Personal Email This field is required. Email is invalid.

Are you of Aboriginal or Torres Strait Islander origin?

No

Yes, Aboriginal

Yes, Torres Strait Islander

Yes, both Aboriginal & Torres Strait Islander

Please select to enter Ahpra or ASAR Registration Number

Ahpra

ASAR

Your Ahpra or ASAR Registration Number This field is required. Ahpra/ASAR is invalid.

Employer Details

Employer Name

This field is required.

Employer Address

This field is required.

Town/ Suburb

This field is required.

State

This field is required.

Postcode

This field is required.

Tel (Work)

This field is required.

Work Email

This field is required.

Add your degree {{ +index + 1 }}

Discipline

Radiography

Radiation Therapy

Nuclear Medicine

Sonography

Other

Country of Qualification

Australia

New Zealand

Other

Name of University This field is required.

Year of Completion This field is required.

Qualification Conferred This field is required.

Degree Level This field is required.

Date Start This field is required.

Application Summary

Subscriber Type

Subscription Period

Subscription Fee

AUD${{ cost }}

Admin Fee

AUD${{ selectedMembershipType['JoiningFee'] }}

Contact

Title:	{{ form_data['contact']['title'] !== 'Other' ? form_data['contact']['title'] : form_data['contact']['other_title'] }}
First name:	{{ form_data['contact']['given_name'] }}
Middle Name:	{{ form_data['contact']['middle_name'] }}
Last Name:	{{ form_data['contact']['surname'] }}
Maiden Name:	{{ form_data['contact']['maiden_name'] }}
Date of Birth:	{{ form_data['contact']['DOB'] \| formatDate }}
Postal Address:	{{ form_data['contact']['postal_address'] }}
Town/Suburb:	{{ form_data['contact']['town'] }}
State:	{{ form_data['contact']['state'] != 'Other' ? form_data['contact']['state'] : form_data['contact']['other_state'] }}
Postcode:	{{ form_data['contact']['postcode'] }}
Country:	{{ form_data['contact']['country'] }}
Tel (home):	{{ form_data['contact']['tel_h'] }}
Tel (mobile):	{{ form_data['contact']['tel_m'] }}
Email:	{{ form_data['contact']['email'] }}
Are you of Aboriginal or Torres Strait Islander origin?	{{ form_data['contact']['aboriginal'] }}
Ahpra/ASAR Registration Number	{{ form_data['contact']['ahpra_number'] }}

Education

Degree {{ +index + 1 }}
Discipline	{{ item['discipline'] }}
Other discipline	{{ item['other_disclipline'] }}
Country	{{ item['country'] }}
Other Country	{{ item['other_country'] }}
Name of University	{{ item['name_university'] }}
Qualification Conferred	{{ item['qualification_conferred'] }}
Completion Year	{{ item['completion_year'] }}

Keep Informed

Join the ASMIRT community and stay up to date. Get the latest news from the Australian Society of Medical Imaging and Radiation Therapy.
We will send you regular updates via our eNews newsletter.

ASMIRT

CONTACT US

Australian Society of Medical
Imaging and Radiation Therapy

Suite 1040-1044 (Level 10),
1 Queens Road Melbourne
VIC 3004 Australia

+61 3 9419 3336

info@asmirt.org

AKNOWLEDGEMENT

Australian Society of Medical Imaging and Radiation
Therapy acknowledges the diverse Aboriginal and Torres
Strait Islander peoples of Australia as the traditional owners
of the lands upon which we and our members operate.
We pay our respects to their Elders, past, present and
future, and value their continued custodianship of the lands,
waters and seas.