*1.Full Name:(Required.)

*2.AusIMM Member Credentials:(Required.)

SAusIMM

GAusIMM

AAusIMM

MAusIMM

MAusIMM(CP)

FAusIMM

FAusIMM(CP)

HonFAusIMM

HonFAusIMM(CP)

*3.Email address:(Required.)

*4.Where are you located?
(Please list your suburb)(Required.)

*5.I am interested in applying for the following position/s in the Southern Queensland Branch committee(Required.)

Chair

Vice Chair

Secretary

Treasurer

Sponsorship Officer

Technical Committee Coordinator

AusIMM COI Partner Lead/s

Awards & Recognition Coordinator

Media Officer

General Committee Member

6.Were you recommended to join the AusIMM Southern Queensland Branch?
If so, please list who by: