Corresponding Membership Application

Corresponding Membership Criteria:

Be nominated and seconded by any two existing members;
Be approved by the Board in accordance with Rule 8.3;
Be approved by the Members in accordance with Rule 8.6;
Be a bona fide Plastic Surgeon who does not reside in Australia or New Zealand or their administered territories;
Be engaged full time or part-time at a Plastic Surgery practice.

Personal Details
Name*
Prefix First Name Last Name
Phone*
Mobile
Email*
Date of Birth
DD slash MM slash YYYY
Spouse's Name
First Last
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Practice Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Qualifications
Medical School
Date of Graduation
DD slash MM slash YYYY
Postgraduate Qualifications (with date)

Membership of Plastic Surgical Associations
FRACS Member
Are you a member of FRACS? (Plastic Surgery)
- Yes
- No
Year Joined
Equivalent Qualification
Degree
Graduation Year
Years in private practice
Number of years in private Plastic Surgical Practice
Other Plastic or Aesthetic Societies
If member of multiple associations or societies, please mention them separated by comma.
Proportion of Aesthetic Surgery
Number of Aesthetic Cases
Signature
I hereby apply for Membership of the Australasian Society of Aesthetic Plastic Surgeons and agree to abide by the Code of Ethics of the Society as a condition of my continuing Membership.
Signature Date
Signature Date
DD slash MM slash YYYY
Proposer
Proposer Name
First Name Last Name
Proposer Contact
Proposer Email
Seconder
Seconder Name
First Name Last Name
Seconder Contact
Seconder Email
Phone
This field is for validation purposes and should be left unchanged.

Personal Details