Application for Admission to Australian Institute of Emergency Services

Instructions

Please use this on-line form to apply for personal membership of the Australian Institute of Emergency Services.

To complete this form you will need the names, email, phone and personal address details of two people who have agreed to be a Referee for you. These two people must have known you for several years and be prepared to attest to your character and background in the Emergency Services.

Please Note:

Please address your application using the drop-down-box to your local Division of the Institute or the Division that represents the area where you live. All fields marked with * must be completed. Please ensure you have submitted a correct email address so we can get back to you.

The cost of Admission is AU$70 ($20 joining fee - $50 annual fee).

The Divisional Registrar processing your application will contact you with details of the progress of your application once it has been received.

---

* To: The Divisional Registrar:  Please Select ACT New South Wales Queensland South Australia Tasmania Victoria

* Your Name:		* Phone:
* Email:		* Type email again:
* Address:		* City, State, Post Code:
* Date of Birth: (dd/mm/yyyy)

* I am

Please Select employed by a volunteer member of

* Name of Organisation:

* Position/Title:

---

Statement of experience and qualifications

(Note you may supply extra, relevant information in the general comments text box at the bottom of the application.

* From	* To	* Appoint/Position - Duties/Responsibilities

Emergency Training Courses

Institution	Course/Year	Result (where applicable)

Qualifications (Degrees, Diplomas etc)

Decorations/Awards etc

---

Referees (Two Persons who have known me for several years and can give evidence of my character and background)

* Name 1		* Email
* Phone		* Address

* Name 2		* Email
* Phone		* Address

Please Enter Any Additional Details You Wish To Have Considered In The Box Below

Please Note: Submitting this form is the same as signing a hard copy. By submitting this form you declare the above particulars to be true and hereby agree to be bound by the Constitution, By-Laws and Code of Ethics of the Institute.

(to get a new image refresh the page (IE) 'reload image' (opera) 'view image' (firefox))

* Before you submit this form!
Please enter the characters in the image above into this box: