Individual SNHN Membership Application Form

SNHN Membership (Individual)

The individual named below hereby applies for Membership of the SNHN Ltd (Sydney North Health Network) pursuant to clause 5 of the constitution.

Individual Details

The individual's aims/objectives are compatible with the objects of SNHN and we agree to be bound by the constitution governing SNHN.

First Name

Last Name

Profession

Related Qualification

Business / Organisation

What is your role in the business / organistion?

Do you have a AHPRA Registration Number?

Yes

If applicable, are you registered or accredited with your peak professional body? (please describe)

AHPRA Registration Number

Preferred Address

Please provide the suburb and postcode of where you live below

Business Address

Phone Number

Email Address

Communication details

Special Interests

Languages Spoken

Please summarise your interest in primary health care in the Sydney North region

Applicant Consent

I have read the Consent Declaration below.

Sydney North Health Network collects personal information about members, necessary for managing the work of the Company and related programs. Such personal details will be handled by the Company staff in accordance with the Privacy and Confidentiality Procedure and Commonwealth and State privacy laws – Commonwealth Privacy Act (1988) - www.oaic.gov.au.

As a member of Sydney North Health Network, I agree to accept and abide by the terms and conditions of the SNHN Company Constitution.

(02) 9432 8250

info@snhn.org.au

Individual SNHN Membership Application Form

Individual Details

Communication details

Applicant Consent

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