Student Membership Application

Personal Details

Name *

Prefix First Name Surname Name

Please attach photo *

Postal Address *

Street Address

Street Address Line 2

Suburb State

Postcode

E-mail: *

Home Telephone (for ATMS office use only)

Mobile:

Birth Date: *

Day Month Year

Gender *

Female Male

Country of Birth *

Do you have residency or permit to work in Australia ?

Yes No

Have you been known under any other name(s)

Yes No

If yes, please state names:

(If your name is different on any of your documents, evidence of legal name change may be required)

Rejoining ATMS

Have you been a previous member of ATMS? *

Yes No

If Yes, membership number

College Enrolment / Qualification Details

Name of qualification being undertaken *

Name of teaching institution you are attending *

Address of teaching institution you are attending

Date studies commenced *

Day Month Year

Expected completion date *

Day Month Year

Do you authorise ATMS to contact your college on your behalf to confirm enrolment or other study details?

Yes No

(NOTE: PLEASE ATTACH PROOF OF CURRENT ENROLMENT.) *

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Additional Information

How did you hear about ATMS? *

ATMS Presentation/Material College Lecturers Your practitioner/friends

Social Media (Please specify)

Other (Please specify)

Checklist

Evidence of current enrolment (NOTE: Letters of Offer or student ID cards are NOT considered sufficient evidence.) Passport sized photograph of yourself Proof of legal name change, if your name is different on any of your documentation.

Have you ever been convicted of a criminal offence, had a complaint made against you considered by acomplaints or disciplinary body including other associations, been suspended or expelled fromanother association, or been investigated, suspended or deregistered as a provider from a health fund? *

Yes No

If yes, Please provide details

I declare that the information in this application and supporting documentation is true and correct. I agree to abide by the ATMS
Constitution, Code of Conduct and official ATMS policies.

Signature

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Date

Day Month Year