FULL MEMBERSHIP APPLICATION

Join us as a Full Member.

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

Please list all qualifications held here. If you hold more than three, please enter additional qualifications under Other Studies.

If you are currently studying, please enter the anticipated date of completion.

Highest Qualification Name

Qualification 1 - Institution

Qualification 1 - Year Awarded

Qualification 2 Name

Qualification 2 - Institution

Qualification 2 - Year Awarded

Qualification 3 Name

Qualification 3 - Institution

Qualification 3 - Year Awarded

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

Please ensure your references follow the Reference Template provided.

Referee 1 Position

Referee 1 Company

Referee 1 Name

Referee 1 Phone

Is this Referee an AIOH Member?

If No - Please submit two reports for assessment with your application

Referee 2 Position

Referee 2 Company

Referee 2 Name

Referee 2 Phone

Is this Referee an AIOH Member?

If No, Please submit two reports for assessment with your application

Current Membership Status

Are you a current member of the AIOH?

Membership of other Professional organisations

Please list any other professional organisations you are a member of.

Academic Transcripts

Report 1

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

Academic Certificate

Report 2

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

Written References 1

Additional Information

Please upload any additional files here.

Written References 2

Please note there is a file size limitation of 10MB. If your document is over 10MB, please compress your file prior to upload.

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

Yes

Would you like to Network and know what is happening in your State?