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Associate Membership - Online Form

    • 1

      Personal Information

    • 2

      Membership Details

    • 3

      Declaration and Consent

    1/3

    Personal Information

    Part A

    Members are Aboriginal Community Controlled Health Services (ACCHSs) led by their respective Aboriginal communities to deliver comprehensive and culturally appropriate primary health care services.

    Aboriginal Community Controlled Health Services (ACCHSs) are non-profit incorporated Aboriginal community-controlled organisations operating in the State which:

    1 Applicant Details

    Required*

    Name of Organisation*

    Act of Incorporation

    Date of Incorporation

    Full Name*

    Email*

    Position

    Signature

    Date*

    Part B

    2 Details of the Organisation

    Required*

    Name of Organisation

    Address

    Postal Address

    Telephone

    Fax

    Chairperson’s Name

    Chairperson’s Phone

    Officer in Charge

    Officer’s Title or Position

    3 Management Committee or Board of Directors

    Names of Board Members

    Copy of Certificate of Incorporation

    Choose File

    No files Selected

    Upload your Certificate of Incorporation file. Max. file size: 3 MB. Accepted files: .pdf .doc .docx.

    Copy of Organisation’s Latest Registered Constitution

    Choose File

    No files Selected

    Upload your Certificate of Incorporation file. Max. file size: 3 MB. Accepted files: .pdf .doc .docx.

    Part C

    4 Nominated by AH&MRC Director for the Respective Region

    Required*

    Select Your Region Below

    Name of Director

    Signature

    5 Seconded by Nearest ACCHS Member Organisation

    Name of ACCHS

    Name of Person

    Position

    Signature

    If you prefer to download the membership application form instead of completing it online, please click here to access the form in PDF format. Once you have filled out the form, you can submit it via email to MMarlowe@ahmrc.org.au

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