2021 New Member Application Form D3

Cosmedicon Special Offer $618.75 (GST Inclusive) - Paid on application. Membership Information Booklet https://cpca.net.au/wp-content/uploads/2021/03/CPCA-Membership-Information-Booklet-Draft-16.03.21.pdf Your application is subject to approval/acceptance by the Membership Committee. Please allow up five business days for a response. Thank you.

Type of Applicant

I am a medical student

I am a registered medical practitioner

I hold a Fellowship in aesthetic/cosmetic medicine

Medical Practitioners who hold a fellowship in aesthetic/cosmetic medicine may apply for equivalence recognition and be considered eligible for CPCA Fellowship.

How did you hear about the CPCA?*

Select or enter value

Applicant's Details

Personal details must match the record contained within AHPRA Medical Register. Check here: https://www.ahpra.gov.au/Registration/Registers-of-Practitioners.aspx

Current Medical Registration No. (in full)*

Title*

First Name*

Middle Name

Last Name*

PRIMARY CONTACT DETAILS

Mobile Phone #*

Business Phone #

Preferred Email Address*

Re-enter Email Address*

Organisation

If applicable.

Address Line 1*

Address Line 2*

SUBURB*

STATE*

COUNTRY*

POST CODE*

Payment - Discounted Membership Fee - $618.75 - Cosmedicon Special Offer

Receipt provided via return email. Payment options: Bank Transfer BSB # 306-089, ACCT # 343-239-3 NAME: Cosmetic Physicians College of Australasia Credit Card: Visa or Mastercard. American Express is not accepted. Provide card details below.

Bank Transfer Payment Number/Receipt Number:

If you paid via bank transfer, please provide bank processing reference number here. Provide bank transaction receipt via document upload facility at foot of form.

Credit card payment

Credit Card #

Expiry Date

Name on the Card

Card Payment Authority

A tick of this box will be taken as authority to debit your credit card with the specified application fee.

Applicant's Declaration

Please provide signed declaration form that can be found here: https://cpca.net.au/wp-content/uploads/2021/11/20211126-Applicants-Declaration.pdf Thank you.

Head & Shoulders Photograph

Confirmed - uploaded.

Processing of application form may be delayed where no photograph provided. Do NOT go to any expense. Will NOT be published anywhere.

Image of passport or drivers licence confirming ID*

Confirmed - uploaded

Uploads

Applicant's Declaration*

Check - I have uploaded my signed declaration form.

File Upload

Drag and drop files here or

Privacy Notice|Report Abuse

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.