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 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. Please ensure you have submitted a correct email address so we can get back to you.

• All fields marked with * must be completed.
• The Divisional Registrar processing your application will contact you with details of the progress of your application once it has been received.
• The cost of Admission is AU $70 ($20 application fee - $50 annual fee). On submission of this form you will be redirected to our secure online payment service. Payment of your application and membership fee is required when submitting this form and can be made using a credit card or PayPal account.

Application form

* To: The Divisional Registrar of

Please Select ACT New South Wales Queensland South Australia Tasmania Victoria

* First Name

* Last Name

* Date of Birth

* Phone

* Email

* Confirm Email

* Street Address

* Suburb or City

* State

Australian Capital Territory Queensland New South Wales Northern Territory South Australia Tasmania Victoria Western Australia Other (International)

Please specify state

* Post Code

* Country

* 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)

(max 2000 characters) - Please email any further information or attachments to the divisional registrar of your state.

Decorations / Awards etc

(max 2000 characters)

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

(max 2000 characters)

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.

Before you submit this form!

Please enter the characters of the image into the text box below.

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