Provisional Membership Application

Join us. This level is the first level of professional membership. 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

*Please note that Yahoo email addresses will direct AIOH emails to Spam. Please check your Junk Mail and add @aioh.org.au to your safe users list.

Gender

Date of Birth

Company

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 Country

Work Postcode

QUALIFICATIONS

Highest Qualification

Undergraduate Postgraduate Other

Qualification 1 - Institution

Qualification 1 - Date Awarded

Qualification 2 - Institution

Qualification 2 - Date Awarded

Qualification 3 - Institution

Qualification 3 - Date 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

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

Basic Principles Course Cert

Please upload if you have completed the Basic Principles Course

Academic Certificate

Report

Please attach a report only if your references are not from an MAIOH (AIOH Full Member).

Written Reference 1

Written Reference 2

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?