application for the cpd program - asmirt · 2020. 10. 30. · program runs for the financial year...
TRANSCRIPT
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APPLICATION FOR THECPD PROGRAM
The following application form is for use by persons wishing to participate in the ASMIRT CPD Program who are not current members of
Australian Society of Medical Imaging and Radiation Therapy (ASMIRT). Participants in the CPD Program will be charged an annual fee of
$242.00 (inc. GST) for 2020/2021. An additional $100.00 Administration Fee also applies.
CONTACT DETAILS
SURNAME
MAIDEN NAME
GIVEN NAMES
TITLE: MR/MRS/MS/MISS/OTHER
DATE OF BIRTH
RESIDENTIAL ADDRESS
TOWN/SUBURB STATE POSTCODE
TEL (HOME) TEL (WORK)
TEL (MOBILE) EMAIL
CONDITIONS
Participants are registered using this form.
Program runs for the financial year from July to June. CPD participants are required to pay an annual fee of $242.00 (inc. GST). This fee includes administration and service
infrastructure supporting the model.
Additional Administration Fee of $100.00 is also applicable. CPD Administration Officer (CPD AO) accepts the registration.
Once enrolled, participant records credits on the ASMIRT CPD database via electronic lodgment.
Note: Although electronic lodgment of CPD activities is available to all participants, evidence to substantiate these claims is the
responsibility of the participant and must be kept for four years following the conclusion of a CPD cycle.
I accept these conditions.
Signed Date
OFFICE USE ONLY
SIGNED (PSM)
PAYMENT RECEIVED RECEIPT NO.
DATE MAILED/EMAILED
Updated Jul 2020 Page 1 of 2
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PAYMENT AUTHORITY
ENTRANCE FEE $100.00
COST (INC. GST) $242.00
TOTAL AMOUNT (INC. GST) $342.00
CHEQUE (Please tick) Please make payable to “Australian Society of Medical Imaging and
Radiation Therapy” (Australian Dollars Only)
CREDIT CARD (Please tick) MASTERCARD VISA AMERICAN
EXPRESS
CREDIT CARD NUMBER
EXPIRY DATE
CCV NO.
(LAST 3 DIGITS ON BACK OF
CARD, OR LAST 4 DIGITS
FOR AMEX)
CARDHOLDER’S NAME
CARDHOLDER’S SIGNATURE
Page 2 of 2
To submit via post, Please print and send to PO Box 16234, Collins Street West, VIC 8007
To submit via email, or click on File > Send file. The form will then attach in your email
client. Forms can be sent to [email protected]
To submit via fax, Please print and fax to 03 9416 0783
mailto:[email protected]
SURNAME: MAIDEN NAME: GIVEN NAMES: TITLE MRMRSMSMISSOTHER: DATE OF BIRTH: TOWNSUBURB: STATE: POSTCODE: TEL HOME: TEL WORK: TEL MOBILE: EMAIL: undefined: SIGNED PSM: PAYMENT RECEIVED: RECEIPT NO: DATE MAILEDEMAILED: MASTERCARD VISA AMERICAN EXPRESSCREDIT CARD NUMBER: MASTERCARD VISA AMERICAN EXPRESSEXPIRY DATE: CCV NO LAST 3 DIGITS ON BACK OF CARD OR LAST 4 DIGITS FOR AMEX: CARDHOLDERS NAME: RESIDENTIAL ADDRESS: RESIDENTIAL ADDRESS2: Paymen type: OffClick here: