New Member Application About YouName(Required) Dr.Mr.Mrs.Ms.MissMx.Prof.Assoc. Prof.Asst. Prof. Title Given Names Surname Gender(Required)-- Select --MaleFemaleNon-binaryTransgenderAgenderMy gender is not listedPrefer not to answerDate of Birth(Required) DD slash MM slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone (Work)Phone (Home)Phone (Mobile)Email(Required) QualificationsPlease list your Medical/Pathology experience below Qualification Name Year completed To be completed in year Name of Institution Actions Edit Delete There are no Qualifications. Add Qualification Maximum number of qualifications reached. Currently working (organisation)(Required) Pathology Experience(Required)Years in trainingPathology Experience(Required)Years in practiceMembership Categories1a. Regular Membership Be a qualified Anatomical Pathologist (with FRCPA or equivalent qualifications) and have had at least 5 years’ experience in Pathology. Regular Membership for Australian residents. (includes GST)...........................$198.00 Regular Membership for overseas residents (does not include GST) ....................$180.00 1b. Registrar Membership Be in a training programme in pathology (as an RCPA registered registrar/trainee) Registrar Membership for Australian residents. (includes GST)....................... $198.00 Registrar Membership for overseas residents (does not include GST) ................$180.00 2. Associate Membership You can register as an Associate Member with our division if you fit into one of the following criteria: Medical Student or medical Science Student, Pathologist in training in training centres not recognised by the RCPA, Medical resident, Member from other relevant medical specialities, Pathologist outside Australasia. Associate Membership for Australian residents. (includes GST)....................... $198.00 Associate Membership for overseas residents (does not include GST) ................$180.00 (Associate members are entitled to notice of General Meetings but not entitled to vote nor be eligible to hold office as a member of the Board)I am applying for(Required) 1A. Australian Regular Member. (includes GST) 1A. Overseas Regular Member. 1B. Australian Registrar. (includes GST) 1B. Overseas Registrar. 2A. Australian Associate Member. (includes GST) 2B. Overseas Associate Member Associate critera(Required)You can register as an Associate Member with our division if you fit into one of the following criteria please -- select --Medical Student or medical Science StudentPathologist in training in training centres not recognised by the RCPAMedical residentMember from other relevant medical specialitiesPathologist outside AustralasiaAdditional information for our future Annual Scientific meetingsPlease indicate the subspecialty(s) in which you are working by ticking the relevant boxes below.(Required) Education in Pathology Bone and Soft Tissue Pathology Breast Pathology Cytology Dermatopathology Digital & Quantitative Pathology Endocrine Pathology Gastrointestinal Pathology Gynaecological Pathology Head & Neck Pathology Liver & Pancreas Pathology Lung Pathology Lymphoma Pathology Neuropathology Ophthalmic Pathology Paediatric & Perinatal Pathology Renal Pathology Uropathology Others... Please specify, (for example Education)(Required) Do you wish to be considered to present at our future Annual Scientific Meeting Companion Sessions on the subspecialty(s) you have chosen?(Required) Yes No PaymentTotal Credit Card(Required)We will reserve the payment amount upon application, and finalise the payment when approved by the Executive Committee. If unsuccessful the reserved payment amount will not be charged and released to your card. MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Security Code Cardholder Name
