SCT Combined Membership Application

SCT Membership Application
Are you;*

Applying for a new membership/changing your membership statusRenewing your membership (if it has lapsed)Returning to work
Were you previously qualified outside of NZ?*

YesNo

Personal Details
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Phone Number*
Work Email*
Personal Email
Current Employment Details
Job Title*
Employer/Hospital*
Work Address*
Include the name of your department
Country*
Charge Physiologists Name*

First NameLast Name
Charge Physiologists Email*
Your charge physiologist will be contacted to approve your membership application.
Current Position Start Date*

DayMonthYear
Date
Current Weekly Work Hours*

Renewal

If your membership with SCT has lapsed you are required to complete this form.
Membership Type*

Associate (studying towards an SCT qualification)Ordinary (holds an SCT or SCST qualification)Affiliate (industry and/or holds other relevant qualifications)
First year as an SCT member;*
Last year as a financial member;*

Payment Info
If your membership application is successful, you will be sent an invoice for SCT membership of $150.
If your return to work application is successful, you will be sent an invoice for the exam fee of $500.
If your international membership application is accepted pending passing the international certification examination, you will be sent an invoice for the exam fee of $500.
Declaration
- I declare that the statements I have made are accurate.
- I declare to be governed by the rules & regulations of the society and advance the objects of the Society.
- I agree to inform the society immediately of any change in circumstances which may affect my right to continue as a member of the society.
- I consent to be a Member of the Society.
- I agree to promptly advise the Society of any change to my name and/or contact details.
A copy of this response will be forwarded to the charge physiologist at your place of work for approval. If your application is succesesful, we will be in contact regarding payment of membership fees.
Signature*

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SCT Membership Application