FULL MEMBERSHIP APPLICATION

Join us. The Membership Co-ordinator will advise you if more information is required prior to being submitted to the Membership & Qualifications Committee.

PERSONAL INFORMATION

Title

Firstname

Surname

Mobile

Gender

Date of Birth

Work Phone

Home Street Address

Home Address Suburb

Home State

Home State if Other

Home Postcode

Home Country

Work Street Address

Work Address Suburb

Work State

Work State if Other

Work Postcode

Work Country

QUALIFICATIONS

Highest Qualification

Undergraduate Postgraduate Other

Qualification 1 - Date Awarded

Qualification 1 - Institution

Qualification 2 - Institution

Qualification 2 - Date Awarded

Qualification 3 - Date Awarded

Qualification 3 - Institution

Other Studies

CURRENT EMPLOYMENT

Company Name

Department

Current Position Title/Role

Years In This Role

In this Role From

In this Role To

Please enter today's date if this is your current role.

Percentage of time spent on OH work in current role

PREVIOUS POSITIONS

Previous Role 1

Previous Employer 1

Years In Previous Role 1

Previous Role 1 Date From

Previous Role 1 Date To

Percentage of time spent on OH work in Previous Role 1

Previous Role 2

Previous Employer 2

Previous Years in Role 2

Previous Role 2 - Date From

Previous Role 2 - Date To

Percentage of time spent on OH work in Previous Role 2

REFEREE INFORMATION

Referee 1 Position

Referee 1 Company

Referee 1 Name

Referee 1 Phone

Referee 2 Position

Referee 2 Company

Referee 2 Name

Referee 2 Phone

Current Membership Status

Membership of other Professional organisations

Academic Transcripts

Report 1

A report is required if your References are not from a MAIOH (AIOH Full Member).

Academic Certificate

Report 2

A Second report is required if your References are not from a MAIOH (AIOH Full Member).

Written References 1

Written References 2

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I agree to allow the AIOH State Liaison Officer (SLO) to access my contact details.

Yes

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