2011- 2012 AVA Membership Application Form

in

Use this form to apply for AVA membership if you have a qualification that entitles you to be registered as a veterinarian in Australia. This form will take approximately 10-15 minutes to complete. All prices are inclusive of GST. Please allow approximately 2 weeks to be processed.

This application form is valid from 1 January 2012 until 30 June 2012. All applicants will be paying for six months' membership that will run from the date joined until 30 June 2012.

All mandatory fields are marked with a red asterisk

1. Personal Details

Type your first name in here

Enter your middle name here

Enter your last name in here

Enter your date of Birth

2. Postal Details

Please complete your postal address.

Type in the postal address you want items to be mailed to.

Type in your postal city / suburb

Select the state you belong to

3. Residential address

Please fill out your residential address below if it is different to mailing address.

Type in the street address that you currently live in.

type in the the suburb / city that you live in

Select the state you belong to

4. Contact Details
Please complete your contact details below.

Type in your home phone number

Type in your work phone number

Type in your fax number

Type in your mobile number

5. Primary Board Registration
Please enter details of your registrations with veterinary boards below.

type in your VSB registration number

6. Degree Specifications

Select the level of degree

Veterinary Degree Specifications

Type in the university you attended

Please type in the month and year that you graduated.

7. Workplace

Your current position

Select the category in which you fit best

Select the option which most closely descibes your current workplace.

Please type in the name of your clinic if you want your clinic added to the Find-a-Vet map on the website

Please type in the address of your clinic if you want your clinic added to the Find-a-Vet map on the website

I hereby consent for the Australian Veterinary Association Limited to use my name and clinic details for the purpose of the Find-a-vet page in the AVA website.

8. Special Interest Groups

Select the Special Interest Group you would like to join. Click here for more information about Special Interest Groups. To find out more about the cost of joining a Special Interest Group, click here to find out more.

Select the option that best descibes you. *Click here for more information on whether you are eligible for a concession fee.

Please download the credit card or direct debit monthly instalment form

Please select a method of payment if you would like to pay you membership by monthly instalments. Please download the Direct Debit Request (DDR) below if you wish to pay monthly transfer by bank account.

Please note that there will be a $5 a month administration fee involved in addition to the membership amount.

By selecting one of the options of monthly payment, you have agreed to the conditions below.

Customer Service Agreement (including Credit Card and Direct Debit payment options): We, The Australian Veterinary Association Limited, acknowledge our commitment to you as the following: Each monthly instalment will be drawn from your nominated credit card account or bank account (in the case of direct debit) on the 15th day of each month. An instalment email reminder will be sent to you at the beginning of each month. If the draw date falls on a non-business day, we will draw the amount on the next available business day. In the event of returned unpaid transactions you will be notified by phone and/or email of the declined payment details and you will have seven (7) working days to pay the returned payment. If the returned payment has not been made within that period of seven (7) working days, an additional fee of $20.00 will be charged per unpaid transaction.

Your commitment (the customer): You (the customer) note your commitment to us as the following: You agree to pay the full AVA membership total in monthly instalments until June 30 the following year. It is your responsibility to ensure sufficient cleared funds are available in your nominated credit card account or bank account (in the case of direct debit) when payments are to be drawn. It is your responsibility to ensure that you supply a valid email address to us for notification purposes. It is your responsibility to advise us if the credit card account or bank account nominated by you to receive the drawings is altered, transferred or closed before the 15th of each month. You may cease the monthly payment arrangement at any time but the remainder amount must be paid in full.

Click here to download Direct Debit Request form (DDR)

Click here to download monthly credit card instalment form

*The form must be signed and faxed back to the AVA on 02 9437 9068 within 2 weeks of application.

9. Declaration

Please nominate how you want to receive notices of AVA Annual Report free of charge.

*After notification is provided to me by email that the annual report will be available on the website and instructions are provided on how to access the report.

Please nominate how you want to receive notices of General Meeting of the AVA free of charge.

*After notification is provided to you by email that the notice of meeting is available on that website and instructions are provided on how to access this notice.

Note where email is nominated as a means of communication in relation to notice of General Meeting or Annual Report the email will be delivered to the email address shown above in Contact Details



Privacy Statement The AVA is committed to maintaining the confidentiality and security of the personal information we hold in accordance with the Privacy Act 1988. Your personal information is collected so we can communicate with you and provide services to you.

Your details may be used to communicate with you about products and services provided by affiliated organisations that your membership entitles you to. You should notify us if you do not want us to use your information in this way, but please be aware that you may not enjoy the full benefits of membership of the AVA if you do this.

My cart