AGPA Membership Form

Membership Application

To apply for membership please complete all questions.
Applicant Name *

Prefix First Name Last Name
Medical Practice Name *
Member of the Australian Health Practitioner Agency *

Yes No
Practice Address

Street Address

Street Address Line 2

Suburb/City State / Territory

Post Code
Postal Address (if different to the above Address)

Street Address

Street Address Line 2

Suburb/City State / Territory

Post Code
E-mail *
Mobile Number
xxxx xxx xxx
Phone Number

Area Code Phone Number
Number of FTE GPs at Practice
To estimate Full Time Equivalent GPs (FTEs) use the latest SWPE value divided by 1000
Additional GP Owners at this Practice (AGPA membership is also covered by this application - email addresses must be unique)

First Name   Last Name
  Email Phone Number

First Name   Last Name
  Email   Phone Number

   First Name   Last Name
   Email   Phone Number

First Name   Last Name
Email   Phone Number

First Name   Last Name
Email      Phone Number
Application Date

Month Day Year
Date

Membership Fee

Practice Component $ 500.00 AUD

Payable for the Member Practice

FTE Component $ 50.00 AUD

$50 per FTE ( To calculate FTE use current SWPE/1000)

Number of FTE

Subtotal $ 0.00 AUD Tax $ 0.00 AUD Total $ 0.00 AUD

Membership Application