New Member Application Form

Surname:

First Name:

Street Address:

Suburb:

City:

Post Code:

Home Number:

Work Number:

Fax Number:

Mobile Number:

Email:

Practice Details

Name of Practice:

Year of First Registration:

Claims Management Information

Bank Account Number:

HealthPAC Agreement Number:

HealthPAC Payee Number:

GST Number:

DECLARATION

I Agree*

* In submitting this application, the application accepts the conditions or membership of SAMCL Ltd and agrees to comply with those conditions.