D.O.B

Address

Residential address* (PO Box not acceptable) ACT NSW NT SA TAS VIC WA

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Professional History

Attach the following Documents:
1. Your CV*, detailing your qualifications and experience (summary of the last 10 years).
2. Transcripts* of your academic qualifications (must be certified).
3. Proof of Clinical Placements and/or Equivalent employment experience in MRI (Not applicable to first year Students).
4. 100-point certified ID check documents. (https://www.health.nsw.gov.au/art/Documents/100-point-id-check.pdf)
To attach multiple documents, Press and hold the Ctrl key while selecting the files

Other Professional Association membership(s)

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Referees

First Referee's Name (include title)


Second Referee's Name (include title)

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Membership Type

Application can be for one of three types:
1.Student Member (full time students) – free of application fee
2.Student Member (part time students) – $50 application fee
3.Ordinary Member (select class below) – $100 application fee

Select the class of membership applied for (refer to Membership Class):

Medical MRI Specialist	Medical Diagnostic MRI Scientist
Medical Diagnostic MRI Practitioner	Specialist MRI Practitioner
Academic and Research person involved with MRI	Technical/ Engineering/ Management
Medical Requestors	Student
Other

*Membership type will be determined upon review of your application.

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Declaration and signature

By signing this declaration, I acknowledge that:
•I have read the Australian Privacy Principles and I understand and consent to how Australian MedialResonance Imaging Association will use my personal information.
•The information I have provided was true and accurate at the time of completion.

Application form appendix A & B

I Agree

Full Name Today's date