VAHPA Membership

Online Application Form

1) Personal Details 2) Membership Type 3) Direct Debit Details 4) Declaration & Submit 5) Finish

My Personal Details

First Name *

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Middle Name

Family Name *

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Preferred Name

Gender

Pronoun

Date of Birth * (DD/MM/YYYY)

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Profession *
(select 'Other' if not listed)

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Graduation Date *
(Early Career membership requires this date)

Please enter Graduation Date

Are you from Aboriginal and/or Torres Strait Islander Origin? *

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Are you applying for student membership?

University*

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Campus*

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Course Studying*

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My Contact Details

Personal Email (primary email)*

Primary Email has already been used

Work Email (alternate email)

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Primary Mobile Number * (It must start with 0 and must be 10-digit long with no spaces.)

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Alternate Number (if a landline, enter the area code and follow with the phone number. It must start with 0 and must be 10-digit long with no spaces.)

My Address

Address line 1 *

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Address line 2

Suburb *

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State *