application for membership - Urological Society of Australia and ...

Urological Society of Australia and New ZealandABN 64 880 438 690APPLICATION FOR MEMBERSHIPType of membershipFULL MEMBER ASSOCIATE MEMBER – UROLOGICAL PROVISIONAL MEMBER ASSOCIATE MEMBER – MEDICAL TRAINEE MEMBER ASSOCIATE MEMBER – RESEARCH CORRESPONDING MEMBER CORRESPONDING MEMBER – UAA Your DetailsTitle: First Name(s): Last Name:Medical Board registrationState jurisdiction (i.e.: ACT, NSW, NZ, Northern/QLD,SA/NT, TAS, VIC, WA):Medical Board registration number:Address for CorrespondenceCity/Suburb State Postcode Country ______Telephone: (Home)(Work)(Mobile) (Fax) ______________Email:Date of Birth: _______________Partner’s DetailsTitle: First Name(s): Last Name:Urological Society of Australia and New ZealandSuite 512 Eastpoint, 180 Ocean Street, Edgecliff NSW 2027Tel: +61 2 9362 8644 Fax: +61 2 9362 1433Email: secretary@usanz.org.au Web: http://www.usanz.org.au

Application ProcessOnce received, your application will be considered at the next Board of Directors’ meeting.Meetings are held in February, May, August and November of each year.You will receive confirmation and an invoice for payment shortly after the meeting.ClassCode2012 inc GST (GST not applicable toNZ members)FULL MEMBER - AUSTRALIA FM $1,581.00FULL MEMBER – NEW ZEALAND FM $ 1368.00 (no GST)FULL MEMBER SENIOR FMS $63.00FULL MEMBER SENIOR – NEW ZEALAND FMS $57.00 (no GST)FULL MEMBER OVERSEAS FMO $242.00PROVISIONAL MEMBER – AUSTRALIA PM $1450.00PROVISIONAL MEMBER – NEW ZEALAND$1,248.00 (no GST)CORRESPONDING MEMBER CO $144.00CORRESPONDING MEMBER – O/seas CO $131.00 (no GST)ASSOCIATE UROLOGICAL MEMBER AUM $1202.00ASSOCIATE UROLOGICAL MEMBER –O/seas AUM $1093.00 (no GST)ASSOCIATE SCIENTIFIC MEMBER ASM $144.00ASSOCIATE MEDICAL MEMBER AMM $268.00TRAINEE MEMBERTMincorporated in USANZ training fee for SET UrologytraineesFELLOW FEL $0HONORARY MEMBER HM $0Please complete these pages and return to:Urological Society of Australia and New ZealandEmail: communication@usanz.org.auFax: +61 2 9362 1433Post:Urological Society of Australia and New ZealandSuite 512 Eastpoint180 Ocean StEdgecliff NSW 2027AustraliaUrological Society of Australia and New ZealandSuite 512 Eastpoint, 180 Ocean Street, Edgecliff NSW 2027Tel: +61 2 9362 8644 Fax: +61 2 9362 1433Email: secretary@usanz.org.au Web: http://www.usanz.org.au

Note – International Medical Graduates (IMGs): IMGs working under oversight may have their'oversight time' as an Associate Urological Member (AUM) recognised, so that this period is taken offthe three year period as a Provisional Member (PM). (Board of Directors Resolution November 2009)(H) ASSOCIATE MEDICAL MEMBERSTo registered medical practitioners resident in Australia or New Zealand and who are a member of anapproved non-urological medical society in Australia or New Zealand and who have an interest incontinuing education in urology.(I) ASSOCIATE SCIENTIFIC MEMBERSTo residents of Australia and New Zealand who are scientists who do not practise urology but who areactively interested in some phase or aspect of urology.(J) HONORARY MEMBERTo persons who, in the opinion of the Board of Directors, have made a distinguished contribution tourology or the Society(K) SENIOR MEMBERA Member in the class of Full Member or Associate Urological Member or Associate Medical Memberor Associate Scientific Member may be classified as “Senior Full Member”, “Senior Associate UrologicalMember” , “Senior Associate Medical Member” or “Senior Associate Scientific Member” respectivelyupon successful application by the member to the Board of Directors after the member has fully retiredfrom practice or has had thirty years membership in their respective class or in other cases asdetermined by the Board of Directors.(L) RESEARCH MEMBERTrainee Members and Full Members, upon application to the Board of Directors, may be grantedResearch Member status for a period not exceeding three years while undertaking a university researchhigher degree in a field related to urology. Each Society member is limited to three years in thismembership category during their lifetime.(M) OVERSEAS MEMBERA Member in the class of Full Member or Associate Urological Member may be classified as “FullMember Overseas” or Associate Urological Member Overseas” respectively if the member istemporarily resident in a single country other than Australia or New Zealand and if the absence is for acontinuous period of more than six months. Like other changes in membership class, an application tothe Board of Directors is required.Urological Society of Australia and New ZealandSuite 512 Eastpoint, 180 Ocean Street, Edgecliff NSW 2027Tel: +61 2 9362 8644 Fax: +61 2 9362 1433Email: secretary@usanz.org.au Web: http://www.usanz.org.au