191 967 A CAAVIC APPLICATION FORM
User Manual: 191-967 A
Open the PDF directly: View PDF 
.
Page Count: 4
| Download | |
| Open PDF In Browser | View PDF |
VIC BRANCH PO Box 13163, Law Courts VIC 8010 40 Dudley Street, West Melbourne, VIC 3003 T: 03 9328 4699 F: 03 9328 2966 www.caavic.asn.au ABN 28 050 191 967 MEMBERSHIP APPLICATION FORM Surname: ....................................................................................... Given Names: ................................................................................ Date of Birth: …………………… Are you a: Locum Sex: M / F (please circle) Associate Principal Are you transferring from another Branch: YES/NO Other ............................................... If Yes, Branch:…………. Contact Details: Private Address Phone: Fax: Mobile: Postcode Postal Address Clinic Name & Practice Address/es 1. Postcode 2. Postcode Phone: X-ray Disabled Access 3. Disabled Access Fax: A/H Emergency: Phone: X-ray Postcode A/H Emergency: Phone: X-ray Postcode Fax: Disabled Access Fax: A/H Emergency: Clinic Website Address: Clinic Email Address: Personal Email Address: _____ _______ preferred email contact preferred email contact The Branch sends out emails from time to time to notify of legislation changes, CA Award updates, job opportunities, seminars, etc. The Branch will not forward your email address to a third party. Please indicate in which category you are applying for membership: Student – Please tick year of study: 1st year 2nd year 3rd year 4th year 5th year Institution attending ………………………………………………………………… Standard Year 1 Member [first year of practice] Standard Year 2 Member [second year of practice] Standard Year 3 Member [third year of practice] Standard Year 4/Full Time Member [fourth year and thereafter] Limited (part-time) Member - Indicate number of hours practiced per week: ………………..… Non Practising Retiree (Over 55 years of age/20 years membership/spec circumstances) Academic - Give Details …………………………………………………………………………… If practising Part-Time, indicate No of hours practised per week: ………………..… Foreign Associate Primary chiropractic qualifications: ............................................................................................................. Institution: ................................................................................ Year granted: .............................................. Other academic chiropractic awards: Award: ...................................................................................... Year granted: .............................................. Institution: ....................................................................................................... .............................................. Tertiary/post-secondary awards in other disciplines: Qualification: ............................................................................ Year granted: .............................................. Institution: ....................................................................................................... .............................................. STUDENTS – go to Declaration by Applicant – Page 4 DOCTORS ONLY - Please complete the following section relating to registration licensure: Chiropractic Practice: AHPRA Registration no: ………………………………................................... Date registered: ...................... X-ray: State/s:............................................. Licence no:...................... Date registered: ………….……… Other professional/paraprofessional registration/licensure: Discipline: ............................................................ Page 2 of 4 – Application for Membership CAAV-059_2 August 2013 Jurisdiction: ................................ .. Please list chiropractic experience (including locums): Location:.......................................................... Dates of Practice ...........................................……….. ............................................................... ....................................………..…… ............................................................... ....................................………..…… ............................................................... ....................................………..…… What languages (other than English) are spoken in your clinic? …………………………………………………………. What techniques are you skilled in and use in your clinic? (please tick a maximum of five only) Activator Applied Kinesiology Cranial Chiropractic Biophysics Chiropractic Ecology Diversified Drop Piece Gonstead Logan Basic Manual NET Neuro Impulse Protocol Soft Tissue TBM Thompson Trigger Point Webster Flexion Distraction Network Spinal Analysis Nimmo SOT Torque Release Toggle Recoil What adjunctive therapies do you use in your clinic? Nutrition Massage Acupuncture Naturopathy Homeopathy Other – please specify …………………………. Psychology/Counselling What areas of special interest do you have (if any)? Sports Chiropractic Paediatric Chiropractic Rehabilitative Chiropractic Animal Chiropractic Chiropractic Neurology Other – please specify ………………………………………………………………… ...................................................... Details of further studies you have completed in these fields: ..................................................................... Do you accept patients for: Department of Veterans’ Affairs (DVA) Transport Accident Commission (TAC) WorkSafe (previously WorkCover) Comcare Do you accept Medicare Enhanced Primary Care (EPC) Referrals? Yes / No If Yes, do you: Bulk bill or Bill the patient Do you have x-ray facilities in your clinic which you use? Yes/No Do you provide after hours/emergency care at your clinic? Yes/No Emergency Contact Number (available to patients): ………………………………………………….. Page 3 of 4 – Application for Membership CAAV-059_2 August 2013 Have you been disciplined by a professional association of which you were a member? Yes / No If yes, specify:.................................................................................................................................. Have you had or are you aware of any malpractice claims against you? Yes / No If yes, specify: .. ............................................................................................................................................. . …………………………………………………………………………………………………………… ..................................................... …………………………………………………………………………………………………………… ..................................................... Have you ever been prosecuted? Yes / No If yes, specify: ................................................................................................................................................. . …………………………………………………………………………………………………………… ..................................................... …………………………………………………………………………………………………………… ..................................................... DECLARATION BY APPLICANT I agree to abide by the Code of Ethics of the Chiropractors' Association of Australia (Victoria) Limited and to observe all rules and regulations within the Memorandum and Articles and By-Laws and any amendments that are made thereto. Membership is continuous until one month’s written notification is provided to the state branch. http://www.caavic.asn.au/home/about-caa I agree to uphold the principles of the Association and to assist in all ways to accomplish its objectives. I agree to pay all dues of the Association and to assist in all ways to accomplish its objectives. I hereby declare that all information given in this application is true and I understand that any misrepresentation on my part whether wilful or unintentional, may cause me to forfeit my membership of this Association. Signature of applicant: ................................................................................. Date: …………………………………… Signature of witness: ................................................................................... Date: …………………………………… I have enclosed a current photograph $ 1 0 0 Appl i c ati on fee to ac c om pany al l member s hi p appl i c ati on s (except students) The application fee will be subtracted from the total of your membership fee. ........... Or ........... I have enclosed a cheque for $100 (please make cheque payable to CAA (National) Ltd Please debit my credit card: Visa Mastercard Card Number: __ __ __ __ / __ __ __ __ /__ __ __ __ /__ __ __ __ Expiry: __ __ / __ __ CCV No __ __ __ __ Name on Card: .............................................................................................................. Signature: ...................................................................................................................... Page 4 of 4 – Application for Membership CAAV-059_2 August 2013
Source Exif Data:
File Type : PDF File Type Extension : pdf MIME Type : application/pdf PDF Version : 1.5 Linearized : Yes Author : Norm Brockley Company : Norm Brockley Create Date : 2013:08:23 12:29:54+10:00 Modify Date : 2013:08:23 12:29:56+10:00 Source Modified : D:20130821053459 Subject : Tagged PDF : Yes XMP Toolkit : Adobe XMP Core 5.2-c001 63.139439, 2010/09/27-13:37:26 Metadata Date : 2013:08:23 12:29:56+10:00 Creator Tool : Acrobat PDFMaker 10.1 for Word Document ID : uuid:71e8045f-f1d3-4bfa-9881-47f33e3ec3c2 Instance ID : uuid:2c8fc523-45ec-480e-9941-2e681ec70d77 Format : application/pdf Title : Description : Creator : Norm Brockley Producer : Adobe PDF Library 10.0 Keywords : Page Layout : OneColumn Page Count : 4EXIF Metadata provided by EXIF.tools