Clone of AGPA Membership Application Form Stripe

Membership Application

To apply for membership please complete all questions.
Applicant Name

PrefixFirst NameLast Name
Medical Practice Name
Registered with the Australian Health Practitioner Agency
Is your Practice Accredited?
Practice Address

Street Address

Street Address Line 2

Suburb/CityState / Territory

Post Code
Postal Address same as Practice Address?
Postal 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 Calculation (AUD)
$500 Practice Fee plus $50 per FTE Plus GST
Payment Method
Direct Deposit Bank Details

Please deposit to Account Name: Australian GP Alliance; BSB: 082-902; Account Number: 241766488. Please use your family name or clinic name as the payment reference.

AUD$500 Practice Fee plus $50 per FTE Plus GST

Membership Application