JOIN

MEMBERSHIP APPLICATION FORM

LAST NAME:
FIRST NAME:
BUSINESS/STUDIO NAME:
SPECIALITY:
(up to 14)
STREET ADDRESS & SUBURB:
POSTAL ADDRESS:
(if different from above)
CITY/TOWN:
PROVINCE:
POSTCODE:
(Postcode Finder)
COUNTRY:
PHONE:
MOBILE:
FAX:
PRIVATE PHONE:
EMAIL:
PASSWORD:
CONFIRM PASSWORD:
WEBSITE: Primary website:

Secondary website:
AGENT WEBSITE:
STOCK WEBSITE:
MEMBERSHIP CATEGORY:
Self Employed
Employee
Student

If Employee or Student please state where:
FEE STRUCTURE:
(all fees include GST)
Joining Fee (Full & Affiliate Only) $81.00
Full Membership $382.50 per annum
Affiliate Membership $382.50 per annum
Emerging Membership $267.75 per annum
Assistant Membersip $153.00 per annum
Student Membership $76.50   per annum
FEE PAYMENT METHOD:
Cheque
Direct Credit
Credit Card
BACKGROUND INFO:
(i.e. industry experience)
DATE OF BIRTH:
NOMINATED BY:
(must be an AIPA member)
  If accepted as a member, I agree to abide by the AIPA Code of Conduct and encourage the        development of the AIPA as set down in the rules of the Association