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MEMBERSHIP APPLICATION FORM

LAST NAME:
FIRST NAME:
BUSINESS/STUDIO NAME:
SPECIALITY:
(up to 9)
STREET ADDRESS & SUBURB:
POSTAL ADDRESS:
(if different from above)
CITY/TOWN:
REGION:
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)
Full Membership $391.00 per annum
Emerging Membership $273.70 per annum
Affiliate Membership $273.70 per annum
International Membership $272.00 per annum
Assistant Membersip $156.40 per annum
Educator Membership $156.40 per annum
Student Membership $78.20   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