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Member Name

	^Title	^Firstname	^Surname
^{*Member Full Name}
^{*Preferred Name}		(This is the name shown on your membership card)

Contact Details

	*Home Postal Address	Work Postal Address
^{Postal Address}


^City
^{Post Code}
^*Country			_{Or other employer}
^{*Employer Name}
^Telephone
^*Email
^*Password

Professional Qualifications

^{*Registration Type}
	If you answered corporate, you do not need to answer the next 2 questions.
^{NCNZ Number}

Educational Qualifications

	Institution	Certificate Name	Year Completed
^{Certificate 1}
^{Certificate 2}
^{Certificate 3}

Statistics

^Ethnicity	NZ Maori	NZ European	Tokelauan	South East Asian
	Indian	Other European	Cook Island Maori	Tongan
	Nuiuean	Chinese	Samoan	Pacific
	Asian	Other
^{Main Clinical Area}

Tick Membership Category below:

Fellow $NZ 305.65
Ordinary Member $NZ 305.65
Associate Member $NZ 153.33
Student Rate $NZ 122.67
Corporate Rate $NZ 889.33

Tick Method of Payment:

Credit Card
Online Banking
Payroll Deduction (Not available for corporate members)
Cheque or Money Order