Application for Enrolment: Non-Member Participant

Application for Enrolment: Non-Member Participant

Please apply in the form below.
Form Nr: CPD424

Last Revised: Oct 2021

Version: 9
Medical practitioners registered to practise in Australia or New Zealand (as applicable) and whose practice is principally in the area of emergency medicine, and are not eligible for membership in any other category may wish to consider applying for admission to College membership as an Educational Affiliate.
Personal/Residential Details
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
ACEM ID (if applicable)
Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState

Post Code
Is your postal address the same as above?*

YesNo
Postal Address*

Street Address

Street Address Line 2

CityState

Post Code
Preferred Contact Number*

Medical Board Registration Details
Select the medical board/s you are registered with*

MCNZ RegistrationAHPRA Registration
MCNZ Registration Number*
Valid Until*

DayMonthYear
Date
AHPRA Registration Number*
Valid Until*

DayMonthYear
Date

Application Fee 2023-2024
Please select your admission period and country of residence:*

CPD Year January to December 2025 - AUSCPD Year January to December 2025 - NZJanuary to June 2025 - AUSJanuary to June 2025 - NZJuly to December 2025 - AUSJuly to December 2025 - NZ
Calculation

My Products*

AUDDescription

I, the cardholder named above, authorise ACEM to debit my credit for the amount indicated in the relevant Fee Schedule above.
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty:

Personal/Residential Details