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Join Now - Associate

Individual Associate Application

	Please download and read the full application form before proceeding.
	This is a tax invoice when accompanied by payment.
Surname *
First name *
Title
Preferred Name
.
Company name (if required)
Company name
Company Street
Company Postcode
Company Country
Company Suburb
.
Street
City
State
Post code
Country
Home phone
Work phone
Work fax
Mobile
Email *
.
Send mail to	WorkHome
Education:	I have attached:-
	A copy of my Diploma in Hearing Device Prescription and Evaluation?
	OR
	A copy of my Master of Audiology or higher postgraduate qualification?
	OR
	A copy of my academic transcript reflecting that I am entitled to a Diploma in Hearing Device Prescription and Evaluation; Master of Audiology or higher postgraduate qualification; and will forward a copy of my certificate or degree as soon as possible. I understand that if I do not provide the Secretariat with a copy of my certificate or degree within a reasonable time; my membership may be downgraded or cancelled.
.
Employment:	Out of the previous 4 years, on a full-time basis, or pro rata on a part-time basis I have been employed in the hearing care industry for how many years?

	AND
	I have attached a Confirmation of Employment form completed and signed by each of my employers over the relevant period?
.
Fees:	I have attached:-
	Payment of the $461.00 membership fee?
	AND
	Payment of the $231.00 application fee
.
Pay by type	ChequePostal orderCredit card

	Credit Card facilities are available for your convenience. Please fill in the information below if you wish to use the credit card facility to pay your membership fees. Please note: a surcharge of 2% will apply to all credit card transactions.
	MastercardVisa
Card Name
Card number
Expiry date
Amount $
	I authorise ACAud to provide relevant membership information to the Office of Hearing Services (as required by the provisions of the Memorandum of Understanding).
	As a member of ACAud I agree to abide by the Code of Ethics?

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