2020 HPMI Individual Membership

Please complete following form to become a HPMI Member.
You MUST answer question re name, contact number and health profession
Ignore other questions if your details are unchanged.
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INDIVIDUAL MEMBERSHIP TYPES
$330 - GP Membership
$165 - AHP Membership (includes Nurses and Administration staff)
$275 - Specialist Membership

COMPLIMENTARY MEMBERSHIP (click here) AVAILABLE TO Health Students, Interns, RMOs & GP Trainees
GROUP MEMBERSHIP (click here)

Question Title

* 1. Name

Title

Given Name

Surname

Question Title

* 2. Health profession

General Practitioner

Specialist - please specify below

Allied Health - please specify below

Administrator or Clerical staff

Nurse

Registrar

Please specify Specialty or Profession

Question Title

* 3. Honours and qualifications

Question Title

* 4. QA or ACRRM (if applicable)

Question Title

* 5. Email address (please supply for provision of meeting information)

Question Title

* 6. Phone Nos.

Business

Mobile (Needed for meeting notifications only)

Fax

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* 7. Surgery Name and Address

Surgery Name:

Surgery Address 1:

Surgery Address 2:

Surgery Address 3:

City/Town:

State/Territory:

Post Code:

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* 8. Preferred mail address (if different from above)

Address 1

Address 2

City/Town

State

Postcode

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* 9. Associated with:

Hunter Primary Care

Hunter Surgical Society