SOMANZ - Application for Membership

Society of Obstetric Medicine
of Australia and New Zealand

Please send completed Application to:

SOMANZ Secretariat
145 Macquarie Street
Sydney NSW 2000
Ph: 61-2-9256 5462
Fax: 61-2-9251 8174
E-mail: sneylon@racp.edu.au

APPLICATION FOR MEMBERSHIP

Surname ________________________________________________________________
Title _________________	Given Name/s ______________________

Address for Correspondence ________________________________________________

_______________________________________________________________________

___________________

Post Code ______________

D.O.B. _______________

Telephone: (______) _________________

Fax: (______) _________________

Email: ___________________@_____________________________________________

I, _____________________________________ hereby apply for membership of SOMANZ.

Signed: _____________________________	Date: ________________________
Nominated by: _______________________	Signature: _____________________
(Please print nominating member's name)	(Nominators signature)

Seconder: __________________________	Signature: _____________________
(Please print seconder's name)	(Seconder's signature)

Supervisor's Name and Signature if applying for student membership
..............................................................................................................................................
Annual Membership (incl. GST)- $44.00 Overseas Membership (incl.NZ) - $40.00	Annual Student Membership(incl. GST)- $22.00 Overseas Student Membersip (incl. NZ) - $20.00

You may pay by cheque made payable to the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) or by Credit Card (Bankcard, Mastercard or Visa Only). Enclose cheque or complete credit card details below and post this form or a copy to the address above. Thank you.

Bankcard / Mastercard / Visa (Please circle card type)

Card Number ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Name on Card ____________________________

Expiry Date _____________

Cardholder's Signature ______________________

Total Paid A$ ____________

For our records, would you please indicate which category best describes your major area of interest.

	Scientist		Obstertrician		Physician		Anaesthetist		Other
								__________________