191 967 A CAAVIC APPLICATION FORM

User Manual: 191-967 A

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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: …………………… Sex: M / F (please circle)
Are you a: Locum Associate Principal Other ...............................................
Are you transferring from another Branch: YES/NO If Yes, Branch:………….
Contact Details:
Private Address
Postcode
Phone:
Fax:
Mobile:
Postal Address
Postcode
Clinic Name & Practice Address/es
1.
Postcode
X-ray
Disabled
Access
Phone:
Fax:
A/H Emergency:
2.
Postcode
X-ray
Disabled
Access
Phone:
Fax:
A/H Emergency:
3.
Postcode
X-ray
Disabled
Access
Phone:
Fax:
A/H Emergency:
Clinic Website Address: _____
Clinic Email Address: _______ preferred email contact
Personal Email Address: 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.
Page 2 of 4 – Application for Membership
CAAV-059_2 August 2013
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: ............................................................ Jurisdiction: ................................ ..
Page 3 of 4 – Application for Membership
CAAV-059_2 August 2013
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 Flexion Distraction Logan Basic Manual
Network Spinal Analysis NET Neuro Impulse Protocol
Nimmo SOT Soft Tissue TBM Thompson Toggle Recoil
Torque Release Trigger Point Webster
What adjunctive therapies do you use in your clinic?
Nutrition Acupuncture Naturopathy Homeopathy Psychology/Counselling
Massage Other – please specify ………………………….
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 4 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
$100 Application fee to accompany all membership applications (except students)
The application fee will be subtracted from the total of your membership fee.
........... 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: ......................................................................................................................
Or

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