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ASMIRT CPD Subscriber Application Form

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

For CPD Subscribers who have their CPD subscription paid by a corporate sponsor.

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Employer Details

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Application Summary

Subscriber Type {{ membership_labels[form_data['membership_type']] }}
Subscription Period {{ form_data['membership_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'] }}

Member Benefit CPD
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ASMIRT

Australian Society of Medical
Imaging and Radiation Therapy
Suite 1040-1044 (Level 10),
1 Queens Road Melbourne
VIC 3004 Australia
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.
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