ASMIRT Membership CPD Application Form

AUSTRALIAN SOCIETY OF MEDICAL IMAGING AND RADIATION THERAPY

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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Add your degree {{ +index + 1 }}

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Application Summary

Membership Type {{ membership_labels[form_data['membership_type']] }}
Membership Period {{ form_data['membership_period'] }}
Membership Fee AUD${{ cost }}
Joining Fee AUD${{ selectedMembershipType['JoiningFee'] }}
Contact
Title: {{ form_data['contact']['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'] }}
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 Trait 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'] }}