Membership Application and Renewal Form New or Exisitng Member?*Please indicate whether you are a new member or an existing member. This will control the questions we ask on the form below.Existing Member RenewalNew MemberPersonal DetailsYour Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Date of birth Date Format: DD slash MM slash YYYY GenderMaleFemaleSpouse Name (if Spouse is a member) Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Contact InformationEmail* Mobile PhoneHome PhoneAddress* Street Address Address Line 2 City State / Territory Post Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Regional AreaSelect multiple regions by holding CMD+click (Mac) or CTRL+click (PC)New South Wales - Capital RegionNew South Wales - Central CoastNew South Wales - Central WestNew South Wales - Coffs Harbour - GraftonNew South Wales - Far West and OranaNew South Wales - Hunter Valley exc NewcastleNew South Wales - IllawarraNew South Wales - Mid North CoastNew South Wales - MurrayNew South Wales - New England and North WestNew South Wales - Newcastle and Lake MacquarieNew South Wales - Richmond - TweedNew South Wales - RiverinaNew South Wales - Southern Highlands and ShoalhavenNew South Wales - Sydney - Baulkham Hills and HawkesburyNew South Wales - Sydney - BlacktownNew South Wales - Sydney - City and Inner SouthNew South Wales - Sydney - Eastern SuburbsNew South Wales - Sydney - Inner South WestNew South Wales - Sydney - Inner WestNew South Wales - Sydney - North Sydney and HornsbyNew South Wales - Sydney - Northern BeachesNew South Wales - Sydney - Outer South WestNew South Wales - Sydney - Outer West and Blue MountainsNew South Wales - Sydney - ParramattaNew South Wales - Sydney - RydeNew South Wales - Sydney - South WestNew South Wales - Sydney - SutherlandNew South Wales - Migratory - Offshore - Shipping (NSW)New South Wales - No usual address (NSW)Victoria - BallaratVictoria - BendigoVictoria - GeelongVictoria - HumeVictoria - Latrobe - GippslandVictoria - Melbourne - InnerVictoria - Melbourne - Inner EastVictoria - Melbourne - Inner SouthVictoria - Melbourne - North EastVictoria - Melbourne - North WestVictoria - Melbourne - Outer EastVictoria - Melbourne - South EastVictoria - Melbourne - WestVictoria - Mornington PeninsulaVictoria - North WestVictoria - SheppartonVictoria - Warrnambool and South WestVictoria - Migratory - Offshore - Shipping (Vic.)Victoria - No usual address (Vic.)Queensland - Brisbane - EastQueensland - Brisbane - NorthQueensland - Brisbane - SouthQueensland - Brisbane - WestQueensland - Brisbane Inner CityQueensland - CairnsQueensland - Darling Downs - MaranoaQueensland - Central QueenslandQueensland - Gold CoastQueensland - IpswichQueensland - Logan - BeaudesertQueensland - Mackay - Isaac - WhitsundayQueensland - Moreton Bay - NorthQueensland - Moreton Bay - SouthQueensland - Queensland - OutbackQueensland - Sunshine CoastQueensland - ToowoombaQueensland - TownsvilleQueensland - Wide BayQueensland - Migratory - Offshore - Shipping (Qld)Queensland - No usual address (Qld)South Australia - Adelaide - Central and HillsSouth Australia - Adelaide - NorthSouth Australia - Adelaide - SouthSouth Australia - Adelaide - WestSouth Australia - Barossa - Yorke - Mid NorthSouth Australia - South Australia - OutbackSouth Australia - South Australia - South EastSouth Australia - Migratory - Offshore - Shipping (SA)South Australia - No usual address (SA)Western Australia - BunburyWestern Australia - MandurahWestern Australia - Perth - InnerWestern Australia - Perth - North EastWestern Australia - Perth - North WestWestern Australia - Perth - South EastWestern Australia - Perth - South WestWestern Australia - Western Australia - Wheat BeltWestern Australia - Western Australia - Outback (North)Western Australia - Western Australia - Outback (South)Western Australia - Migratory - Offshore - Shipping (WA)Western Australia - No usual address (WA)Tasmania - HobartTasmania - Launceston and North EastTasmania - South EastTasmania - West and North WestTasmania - Migratory - Offshore - Shipping (Tas.)Tasmania - No usual address (Tas.)Northern Territory - DarwinNorthern Territory - Northern Territory - OutbackNorthern Territory - Migratory - Offshore - Shipping (NT)Northern Territory - No usual address (NT)Australian Capital Territory - Australian Capital TerritoryAustralian Capital Territory - Migratory - Offshore - Shipping (ACT)Australian Capital Territory - No usual address (ACT)Other Territories - Other TerritoriesOther Territories - Migratory - Offshore - Shipping (OT)Other Territories - No usual address (OT)Professional StatusResidency*I am an Australian CitizenI am an Australian ResidentOther, please specifyResidency - Other (Please Specify)*Professional StatusGraduate Full-timeGraduate Part-timeGraduate RetiredGraduate Full-time Non-medical MinistryPostgraduate Year 1Postgraduate Year 2Associated ProfessionMissionaryStudent of Medicine, Dentistry or related Health DisciplineProfessional Areas of WorkMedicalDentalAllied HealthOtherEducation InformationGrad year or expected year studies to be completedPlease enter a number from 1900 to 2100.UniversitySpecialtyDental SpecialtyCosmetic DentistryDento Maxillofacial RadiologistEndodontistGeneral DentistOral and Maxillofacial SurgeryOral MedicineOral PathologyOrthodontistPaediatric DentistryPeridontistProsthodontistMedical SpecialtyAnaesthesiaDermatologyEmergency MedicineGeneral PracticeInternal MedicineMedical AdministrationNeonatologyObstetrics & GynaecologyPathologyPaediatric medicinePaediatric SurgeryPalliative MedicinePublic HealthPsychiatryOtherRadiology & Diagnostic ImagingRehabilitation MedicineSurgerySubspecialties of SurgeryCardio-thoracicSurgeryColo-rectal surgeryEndocrine surgeryENT- Head & Neck SurgeryGeneralNeurosurgeryOphthalmologyOrthopaedic SurgeryUpper GIT surgeryPlastic surgeryUrologyVascular surgeryOther surgerySubspecialties of Internal MedicineCardiologyEndocrinologyGastroenterologyGeneral medicineGeriatricsHaematology & OncologyImmunology & AllergyNeurologyPalliative MedicineRenal MedicineRespiratory MedicineRheumatologyOther internal medicineAssociated ProfessionsDental assistant & therapyOccupational therapyPharmacyPhysiotherapyRadiography and ultrasound technologySpeech pathologyNurseOtherAssociated Professions - otherMain Affiliated HospitalTeaching HospitalsACT Teaching HospitalsCalvary Public HospitalCanberra HospitalNSW Teaching HospitalsAlbury HospitalBankstown HospitalBelmont HospitalBlacktown District HospitalBraeside HospitalCalvary HospitalCamden HospitalCampbelltown HospitalCanterbury HospitalCoffs Harbour HospitalDubbo Base HospitalGosford District HospitalHawkesbury District HospitalHornsby District HospitalJohn Hunter Hospital NewcastleLiverpool HospitalMaitland HospitalManly HospitalMona Vale HospitalNepean HospitalOrange Base HospitalPort Macquarie HospitalPrince of Wales HospitalRoyal Hospital for WomenRoyal North Shore HospitalRoyal Prince Alfred HospitalRyde District HospitalSacred Heart HospitalSt George HospitalSt Margarets HospitalSt Vincents HospitalSutherland District HospitalSydney Adventist HospitalSydney Childrens HospitalTamworth Base HospitalWagga Wagga HospitalWar Memorial HospitalWestmead Children's HospitalWestmead HospitalWollongong HospitalVIC Teaching HospitalsAlfred HospitalAngliss HospitalAustin HospitalBallarat HospitalBendigo HospitalBox Hill HospitalCabrini Hospital (private)Casey HospitalDandenong HospitalFrankston HospitalGeelong HospitalLatrobe Regional Hospital (Traralgon)Maroondah HospitalMildura HospitalMonash Medical Centre ClaytonMonash Medical CentreMoorabbin Northern HospitalRoyal Children's HospitalRoyal Melbourne HospitalRoyal Women's HospitalSale HospitalSandringham HospitalSt Vincent's HospitalSunshine HospitalWarrnambool HospitalWestern HospitalQLD Teaching HospitalsBundaberg HospitalCaboolture HospitalCairns Base HospitalGold Coast HospitalHervey Bay HospitalIpswich HospitalLogan HospitalMackay Base HospitalMaryborough HospitalMater Adult HospitalMater Children's HospitalMater Mothers' HospitalMount Isa HospitalNambour HospitalPrincess Alexandra HospitalQueen Elizabeth II Jubilee HospitalRedcliffe HospitalRockhampton HospitalRoyal Brisbane and Women's HospitalRoyal Children's HospitalThe Prince Charles HospitalThe Townsville HospitalToowoomba HospitalSA Teaching HospitalsClare District HospitalFlinders Medical CentreGawler Health ServiceLyell McEwin HospitalModbury Public HospitalMount Gambier & District Health ServiceNoarlunga Health ServicePort Augusta HospitalRepatriation General HospitalRoyal Adelaide HospitalThe Queen Elizabeth HospitalVictor Harbour-South Coast District HospitalWhyalla HospitalWomen's & Children's HospitalWA Teaching HospitalsAlbany Regional HospitalBunbury Regional HospitalCarnarvon Regional HospitalFremantle HospitalGeraldton Regional HospitalKalgoorlie Regional HospitalPrincess Margaret Hospital (Children's)King Edward Memorial Hospital for WomenMount HospitalPerthNickol Bay HospitalNortham Regional HospitalPort Hedland Regional HospitalPrincess Margaret Hospital for ChildrenRoyal Perth HospitalRoyal Perth Rehabilitation HospitalSir Charles Gairdner HospitalWoodside Maternity HospitalNT Teaching HospitalsAlice Springs HospitalDarwin HospitalKatherine HospitalTAS Teaching HospitalsLaunceston General HospitalNorth-West Regional Hospital BurnieRoyal Hobart HospitalStatement of FaithCMDFA Statement of Faith: We believe in the Revelation of the One true God (Father, Son and Holy Spirit), and the Gospel of redemption and regeneration through the incarnation, the death, and the bodily resurrection of our Lord Jesus Christ. We believe in the indwelling of the Holy Spirit until, Christ returns finally to fulfill all things in Himself as it is given to us in the Bible, which is the divinely appointed authority for faith and life. Declaration of Faith In joining the CMDFA Inc, I declare my faith in God the Father, and in God the Son, the Lord Jesus Christ who is my Saviour.I desire to be ruled by the Holy Spirit speaking through the Bible, the divinely appointedauthority in matters of faith and life.I am in agreement with the declaration of faith and will abide by the rules of the CMDFA Inc. as set out in its Constitution. CMDFA-Constitution-amend071114 CMDFA-Constitution-amend071114 (249 KB)Consent* I agree to the Faith Declaration above.Nominators name*Nominator must be a current financial CMDFA Member.Communication PreferencesOpt-in communication preferences Select All I would like to receive mail I would like to receive email I would like to receive SMS I would like to be included in the Members' Directory Listing and access to Members' Directory is only available to financial members.Membership OptionsMembership Options*Standard Membership - $420/yrIntroductory Membership - $140 first yearAllied Healthcare Workers - $140/yrGraduates, part-time 8-25 hours - $280/yrGraduates, part-time less than 8 hours - $75/yrRetirees and Grads not in active practice - $75/yrPostgraduate Year 1 and 2 - $280/yrDoctors in Training $280'/yrSpouse, non Medical/Dental - $280/yrStudent Members - FreeOverseas Missionary - FreePartnership Membership*Quartz - $100/yrOnyx - $200/yrEmerald - $400/yrRuby - $600/yrOpal - $800/yrSapphire - $1,250/yrJade - $1,500/yrPearl - $2,500/yrAmethyst - $3,000/yrDiamond - $5,000/yrNo additional partnershipPayment OptionsNone/freeCredit CardDirect TransferDirect DebitTotal $ 0.00 Memberships and Partnerships may be tax deductible. Please consult your accountant or tax adviser.Credit Card*Credit card payments are processed securely by our external payment gateway. No credit card information is on the site. MasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name CommentsThis field is for validation purposes and should be left unchanged.