New Application Associate Membership

Please attach photo*

Browse Files
Please attach Cancelof
Please attach one of the following as a form of identification (Driver's License, Birth Certificate, or Passport)*

Browse Files
Please attach Cancelof
Name*

First NameFamily Name
Have you been known under any other name(s)

YesNo
If yes, please state names:
(If your name is different on any of your documents, evidence of legal name change may be required)
Birth Date:*

DayMonthYear
Place of Birth *
Country
Postal Address*

Street Address Line 1

Street Address Line 2

CityState

Post Code
E-mail For ATMS Use*
example@example.com
Mobile Phone Number:*

Area CodePhone Number
Home Telephone (for ATMS office use only)

Area CodePhone Number
Rejoining
Have you been a previous member of ATMS? *

YesNo
If Yes, membership number

Payment Details (The ATMS membership cycle runs from July to June. No pro-rata of fees.)
Select Membership Cycle

Membership June 2024 - July 2025 - $100
Have you ever been convicted of a criminal offence, had a complaint made against you considered by a complaints or disciplinary body including other associations, been suspended or expelled from another association, or been investigated, suspended or deregistered as a provider from a health fund?

YesNo
If yes, Please provide details
Signature

Clear
Print Name
Date

DayMonthYear
Should be Empty: