St George Division of General Practice Membership Form

St George Division of General Practice Membership Form

Please note: This form is used for both membership renewals and new membership applications. For new applicants, submission of this form does not confirm membership. All new applications are subject to review and approval by the Division’s Executive Committee. You will be notified once a decision has been made.
Doctor Name*

First NameLast Name
RACGP QA No*
Practice Address*

Address Line 1

Address Line 2

CityState

Pin Code
Mobile Number*
Please enter a valid phone number.
Practice Phone No*

Area CodePhone Number
Practice Fax No

Area CodePhone Number
Email*
example@example.com
PLEASE NOTE: This membership enables GP members access to CESPHN Educational activities including the Peer Group Learning Program.

General Membership requirements:

1) Practicing GP
2) Working in the St George Area
3) Doctor of good standing

If you don’t meet this criteria please register for associate membership. Associate members have access to our educational and social events but do not have voting rights.
Membership Type:*

General Member (Membership Fee: $150)Associate Member (Membership Fee: $150)GP Regsitrar (Membership Fee: $0)Life Member (Membership Fee: $0)
Method of payment:
Direct Deposit (Please include your name when making a payment)
Bank: Commonwealth Bank
Account Name: St George District Division of General Practice Inc.
Account Details: BSB 062 137 Account No. 1000 9498
Consent*

I give consent for my photograph to be used by the St George Division of General Practice for social media and the Division newsletter.I give my permission to share my details with other “board approved” organisations for the purpose of communicating with members.
If you do NOT wish to provide permission for the above, please email admin@stgdgp.org.au with a brief explanation.

Please note: without permission, you will be unable to proceed with the online submission and will need to complete the manual FORM instead.
Consent Date*

MonthDayYear
Date
Should be Empty: