AUSTRALIAN HAND THERAPY ASSOCIATION INC.

PO Box 182  MUNDARING  WA  6073  Australia

Phone: + 61 8 9578 3348   Fax:  + 61 8 9574 6078

E-mail: info@ahta.com.au

 

 

APPLICATION FOR MEMBERSHIP

 

I hereby apply for membership as a:        

1. PERSONAL DETAILS

Title:

First Name:
Surname:
Date of Birth:
Work Address:
City/Suburb:
State/Territory:
Post Code:
Country:
Work Phone:
Work Fax:
Home Address:
City/Suburb:
State/Territory:
Post Code/Zip Code:
Country:
Home Phone:
Mobile:
E-mail
Preferred Mail Address:
Applicants Signature:
Date:

2. APPLICANT'S RECOMMENDATION DETAILS

Recommended by:
Name:
Address:
Phone:

N.B.  All Associate applicants must submit a letter from a recommending Full Member of either the Australian Hand Therapy Association Inc. or the Australian Hand Surgery Society. Member applicants must submit a statement of recommendation from their AHTA Divisional Mentor. Associate applicants must also submit a signed statement acknowledging they understand the distinction between Full and Associate membership status.

3. EDUCATION (Qualifications achieved/year gained)

1.
2.
3.
4.

Copies (not originals) of qualifications must be attached i.e. Degree/Diploma/CHT

4. OT/PT EXPERIENCE

Minimum 3 years equivalent full-time experience post-graduation as an Occupational Therapist or Physiotherapist and State registration where appropriate.

Employer 1

Institution:
Area of Work:
Years:

 

Employer 2

Institution:
Area of Work:
Years:

 

Employer 3

Institution:
Area of Work:
Years:

 

Employer 4

Institution:
Area of Work:
Years:

 

5. PROFESSIONAL HAND THERAPY EXPERIENCE

Minimum 3600 hours of clinical hand therapy experience required.  Employment Verification form must be attached.

6. PROFESSIONAL DEVELOPMENT EDUCATION

Evidence of Participation form, detailing participation in a minimum of 300 hours of professional development/education within the maximum time frame of the last 5 years, must be attached.

7. HAND THERAPY ASSOCIATION MEMBERSHIP DETAILS

Association: Level of membership:
Date joined: Date fees last paid:

8. APPLICATION SUBMISSION CHECK LIST

Before mailing your application, and to avoid delays in processing your application, please ensure you have included the following as appropriate:

Completed Application Form (Member, Associate & Subscriber applications)

Letter of recommendation (Associate applications) from a Member of the AHTA or the AHSS
Reference & statement of recommendation (Member application only) from your AHTA Mentor
Completed Employment Verification Form (Member application only)
Completed Evidence of Professional Development/Education Participation Form (Member application only)
Proof of current AHTA Associate membership or of IFSHT member organisation (Member application only)

Copy of your Degree or Diploma (Member & Associate applications)

Copy of your current Registration Certificate (Member & Associate applications) (if applicable in your state or territory)

Signed statement acknowledging you understand the distinction between Member and Associate status (Associate application only)

Cheque or Money Order for $77.00 for new Member application, $33.00 for an upgrade from Associate to Member, $44.00 for an Associate application, $50.00 for Subscriber (Australia) or $60.00 for Subscriber (overseas).

9. AMOUNT & METHOD OF APPLICATION FEE PAYMENT

Application Type

Cheque/MO/EFT

 Credit Card
New Full Member   $77.00 Inc GST   $79.30 Inc GST
Associate

  $44.00 Inc GST

   $45.30 Inc GST
Upgrade to Full Member

  $33.00 Inc GST

   $34.00 Inc GST
Subscriber (Australia)

  $50 Inc GST

   $51.50 Inc GST
Subscriber (Overseas)

  $60.00 GST free

   $61.80 GST free

 

Select payment method (click down-arrow)

 

Select card type

    Visa

  MasterCard 

Card Nš

   Expires:
Name on Card

Signature: (required)

For credit card or direct deposit payments, please fax completed form to 08 9574 6078
 

If paying by direct deposit, please quote your surname to identify your online payment.
Bank: Bank of Queensland
BSB: 124-001
A/c Nš: 11244637
A/c Title: Australian Hand Therapy Association Inc.

If paying by cheque, please mail to:    AHTA Inc. PO Box 182  MUNDARING  WA  6073

 

ONCE COMPLETED, PLEASE MAIL THIS FORM, TOGETHER WITH THE APPROPRIATE  DOCUMENTATION AND APPLICATION FEE TO:

 

AHTA INC.

PO BOX 182

MUNDARING  WA  6073

AUSTRALIA