Australasian Institute of Emergency Services - Personal Membership Application Form

Application for Admission to Australasian Institute of Emergency Services

Instructions
Please use this on-line form to apply for personal membership of the Australasian Institute of Emergency Services.

To complete this form you will need the names, email, phone and personal address details of two people who have agreed to be a Referee for you. These two people must have known you for several years and be prepared to attest to your character and background in the Emergency Services.

Please address your application using the drop-down-box to your local Division of the Institute or the Division that represents the area where you live. Please ensure you have submitted a correct email address so we can get back to you.

All fields marked with * must be completed.
The Divisional Registrar processing your application will contact you with details of the progress of your application once it has been received.
The cost of Admission is the AU $80 annual fee. Payment is required with your application. When you have completed the form and click on the SUBMIT button you will be redirected to our secure online payment system. Payment can be made using your credit card or PayPal.
Please do not enter < or > characters into this form as it may be blocked for security reasons.

Application Form

* To: The Divisional Secretary of

* First Name

* Last Name

* Date of Birth

* Phone

* Email

* Confirm Email

* Street Address

* Suburb or City

* State

* Please specify state

* Post Code

* Country

* I am

* Name of Organisation

* Position / Title

Statement of experience and qualifications

(Note you may supply extra, relevant information in the general comments text box at the bottom of the application.

* From	* To	* Appoint/Position - Duties/Responsibilities
Invalid date	First experience 'to' date is required Invalid date
Invalid date	Invalid date
Invalid date	Invalid date
Invalid date	Invalid date

Emergency Training Courses

Institution	Course / Year	Result (where applicable)

Qualifications (Degrees, Diplomas etc)

(max 2000 characters) - Please email any further information or attachments to the divisional secretary of your state.

Decorations / Awards etc

(max 2000 characters)

Referees

Two persons who have known me for several years and can give evidence of my character and background.

* Name 1	First reference name is required	* Email	First reference email is required
* Phone	First reference phone is required	* Address	First reference address is required
* Name 2	Second reference name is required	* Email	Second reference email is required
* Phone	Second reference phone is required	* Address	Second reference address is required

Any Additional Details You Wish To Have Considered

(max 2000 characters)

Where did you hear about AIES?

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Please Note

Submitting this form is the same as signing a hard copy. By submitting this form you declare the above particulars to be true and hereby agree to be bound by the Constitution, By-Laws and Code of Ethics of the Institute.