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Associate Membership - Online Form

    • 1

      Personal Information

    • 2

      Membership Details

    • 3

      Declaration and Consent

    1/3

    Personal Information

    Part A

    Members are Aboriginal Community Controlled Health Services (ACCHSs) led by their respective Aboriginal communities to deliver comprehensive and culturally appropriate primary health care services.

    Aboriginal Community Controlled Health Services (ACCHSs) are non-profit incorporated Aboriginal community-controlled organisations operating in the State which:

    1 Applicant Details

    Required*

    Name of Organisation*

    Act of Incorporation*

    Date of Incorporation*

    Full Name*

    Position*

    Signature*

    Date*

    Part B

    2 Details of the Organisation

    Required*

    Name of Organisation*

    Address*

    Postal Address*

    Telephone*

    Fax*

    Chairperson’s Name*

    Chairperson’s Phone*

    Officer in Charge*

    Officer’s Title or Position*

    3 Management Committee or Board of Directors

    Names of Board Members*

    Copy of Certificate of Incorporation*

    Choose File

    No files Selected

    Upload your Certificate of Incorporation file. Max. file size: 3 MB. Accepted files: .pdf .doc .docx.

    Copy of Organisation’s Latest Registered Constitution*

    Choose File

    No files Selected

    Upload your Certificate of Incorporation file. Max. file size: 3 MB. Accepted files: .pdf .doc .docx.

    Part C

    4 Nominated by AH&MRC Director for the Respective Region

    Required*

    Select Your Region Below

    Name of Director**

    Signature*

    5 Seconded by Nearest ACCHS Member Organisation

    Name of ACCHS**

    Name of Person*

    Position*

    Signature*

    If you prefer to download the membership application form instead of completing it online, please click here to access the form in PDF format. Once you have filled out the form, you can submit it via email to MMarlowe@ahmrc.org.au

    Need Help to Fill Up the Form?

    If you have any questions or need more information, please don’t hesitate to contact our customer support team.

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