AGPA Membership Form

Membership Application

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

PrefixFirst NameLast Name
Medical Practice Name*
Member of the Australian Health Practitioner Agency*

YesNo
Practice Address

Street Address

Street Address Line 2

Suburb/CityState / Territory

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

Street Address

Street Address Line 2

Suburb/CityState / Territory

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

Area CodePhone 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

MonthDayYear
Date
Membership Fee
prevnext( X )
Practice Component$500.00AUD
Payable for the Member Practice

FTE Component$50.00AUD
$50 per FTE

Number of FTE

Subtotal $0.00AUDTax $0.00AUDTotal $0.00AUD
Membership payments are annual and are due on either 1 April or 1 October (depending on which gives you the longest initial membership period when you join).

Please make payment to:

Account Name: Australian GP Alliance

BSB: 082-902

Account Number: 24176 6488
Should be Empty:

Membership Application