ASMIRT CPD Subscriber Application Form

AUSTRALIAN SOCIETY OF MEDICAL IMAGING AND RADIATION THERAPY

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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
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'] }}