Associate Membership Application Form

Other Title *

First Name *

Middle Name

Surname *

Preferred Name

Date of Birth *

Email Address *

Mobile Phone *

Private Phone

Do you identify as Aboriginal and/or Torress Strait Islander *

Private Address *

Street address *Street address line 2

City *

State *

Postcode *

Is postal address the same as personal address?

Postal Address

Street address

City

State

Postcode

Name of principal pharmacy employed at

Registration Date *

AHPRA number *

PSA Member *

YesNo

PSA Number *

Have you completed a Graduate Certificate of Advanced Practice and Prescribing for Pharmacists or equivalent? *

YesNo

Graduation Date *

Please select *

Signature *

Draw signature|Type signatureClear

Date *

PRIVACY COLLECTION NOTICE

By submitting this completed application Form, you acknowledge that your personal information including your name, address, phone number and email address (Personal Information) is being provided to The Pharmacy Guild of Australia, Australian Capital Territory Branch, ABN 99 466 762 435. The Personal Information you provide will be used by the Branch to administer and manage your membership, and to keep you informed about developments in the practice of pharmacy, and to send you marketing material about associated products, offers, services and events relating to community pharmacy (Services). The Branch is a branch of The Pharmacy Guild of Australia ABN 84 519 669 143 (the Guild) and, as such, may disclose your Personal Information to the Guild’s National Secretariat, to other branches of the Guild, to the Guild’s and the Branch’s related bodies corporate, and to agents, contractors service providers and partners engaged by the Branch or the Guild to provide the Services. The Branch will not otherwise use or disclose your Personal Information, unless you have given consent, or the Branch is authorised or required to do so by law. For more information about how the Branch and the Guild handles your Personal Information, how you can request to access, correct or update the Personal Information the Branch holds about you, and who to contact if you have a privacy enquiry or complaint, please see the Guild’s Privacy Policy on the website www.guild.org.au. If you elect not to provide your consent to any or all of the uses or disclosures of your Personal Information proposed in this Form, we may be unable to process your membership application and/or provide the Services to you. You can also withdraw your consent at any time, by just letting us know.

PRIVACY COLLECTION NOTICE

By submitting this completed application Form, you acknowledge that your personal information including your name, address, phone number and email address (Personal Information) is being provided to The Pharmacy Guild of Australia, New South Wales Branch, ABN 87 740 877 429. The Personal Information you provide will be used by the Branch to administer and manage your membership, and to keep you informed about developments in the practice of pharmacy, and to send you marketing material about associated products, offers, services and events relating to community pharmacy (Services). The Branch is a branch of The Pharmacy Guild of Australia ABN 84 519 669 143 (the Guild) and, as such, may disclose your Personal Information to the Guild’s National Secretariat, to other branches of the Guild, to the Guild’s and the Branch’s related bodies corporate, and to agents, contractors service providers and partners engaged by the Branch or the Guild to provide the Services. The Branch will not otherwise use or disclose your Personal Information, unless you have given consent, or the Branch is authorised or required to do so by law. For more information about how the Branch and the Guild handles your Personal Information, how you can request to access, correct or update the Personal Information the Branch holds about you, and who to contact if you have a privacy enquiry or complaint, please see the Guild’s Privacy Policy on the website www.guild.org.au. If you elect not to provide your consent to any or all of the uses or disclosures of your Personal Information proposed in this Form, we may be unable to process your membership application and/or provide the Services to you. You can also withdraw your consent at any time, by just letting us know.

PRIVACY COLLECTION NOTICE

By submitting this completed application Form, you acknowledge that your personal information including your name, address, phone number and email address (Personal Information) is being provided to The Pharmacy Guild of Australia, Northern Territory Branch, ABN 29 970 924 913. The Personal Information you provide will be used by the Branch to administer and manage your membership, and to keep you informed about developments in the practice of pharmacy, and to send you marketing material about associated products, offers, services and events relating to community pharmacy (Services). The Branch is a branch of The Pharmacy Guild of Australia ABN 84 519 669 143 (the Guild) and, as such, may disclose your Personal Information to the Guild’s National Secretariat, to other branches of the Guild, to the Guild’s and the Branch’s related bodies corporate, and to agents, contractors service providers and partners engaged by the Branch or the Guild to provide the Services. The Branch will not otherwise use or disclose your Personal Information, unless you have given consent, or the Branch is authorised or required to do so by law. For more information about how the Branch and the Guild handles your Personal Information, how you can request to access, correct or update the Personal Information the Branch holds about you, and who to contact if you have a privacy enquiry or complaint, please see the Guild’s Privacy Policy on the website www.guild.org.au. If you elect not to provide your consent to any or all of the uses or disclosures of your Personal Information proposed in this Form, we may be unable to process your membership application and/or provide the Services to you. You can also withdraw your consent at any time, by just letting us know.

PRIVACY COLLECTION NOTICE

By submitting this completed application Form, you acknowledge that your personal information including your name, address, phone number and email address (Personal Information) is being provided to The Pharmacy Guild of Australia, Queensland Branch, ABN 87 076 197 623. The Personal Information you provide will be used by the Branch to administer and manage your membership, and to keep you informed about developments in the practice of pharmacy, and to send you marketing material about associated products, offers, services and events relating to community pharmacy (Services). The Branch is a branch of The Pharmacy Guild of Australia ABN 84 519 669 143 (the Guild) and, as such, may disclose your Personal Information to the Guild’s National Secretariat, to other branches of the Guild, to the Guild’s and the Branch’s related bodies corporate, and to agents, contractors service providers and partners engaged by the Branch or the Guild to provide the Services. The Branch will not otherwise use or disclose your Personal Information, unless you have given consent, or the Branch is authorised or required to do so by law. For more information about how the Branch and the Guild handles your Personal Information, how you can request to access, correct or update the Personal Information the Branch holds about you, and who to contact if you have a privacy enquiry or complaint, please see the Guild’s Privacy Policy on the website www.guild.org.au. If you elect not to provide your consent to any or all of the uses or disclosures of your Personal Information proposed in this Form, we may be unable to process your membership application and/or provide the Services to you. You can also withdraw your consent at any time, by just letting us know.

PRIVACY COLLECTION NOTICE

By submitting this completed application Form, you acknowledge that your personal information including your name, address, phone number and email address (Personal Information) is being provided to The Pharmacy Guild of Australia, South Australia Branch, ABN 38 946 547 960. The Personal Information you provide will be used by the Branch to administer and manage your membership, and to keep you informed about developments in the practice of pharmacy, and to send you marketing material about associated products, offers, services and events relating to community pharmacy (Services). The Branch is a branch of The Pharmacy Guild of Australia ABN 84 519 669 143 (the Guild) and, as such, may disclose your Personal Information to the Guild’s National Secretariat, to other branches of the Guild, to the Guild’s and the Branch’s related bodies corporate, and to agents, contractors service providers and partners engaged by the Branch or the Guild to provide the Services. The Branch will not otherwise use or disclose your Personal Information, unless you have given consent, or the Branch is authorised or required to do so by law. For more information about how the Branch and the Guild handles your Personal Information, how you can request to access, correct or update the Personal Information the Branch holds about you, and who to contact if you have a privacy enquiry or complaint, please see the Guild’s Privacy Policy on the website www.guild.org.au. If you elect not to provide your consent to any or all of the uses or disclosures of your Personal Information proposed in this Form, we may be unable to process your membership application and/or provide the Services to you. You can also withdraw your consent at any time, by just letting us know.

PRIVACY COLLECTION NOTICE

By submitting this completed application Form, you acknowledge that your personal information including your name, address, phone number and email address (Personal Information) is being provided to The Pharmacy Guild of Australia, Tasmania Branch, ABN 25 957 305 960. The Personal Information you provide will be used by the Branch to administer and manage your membership, and to keep you informed about developments in the practice of pharmacy, and to send you marketing material about associated products, offers, services and events relating to community pharmacy (Services). The Branch is a branch of The Pharmacy Guild of Australia ABN 84 519 669 143 (the Guild) and, as such, may disclose your Personal Information to the Guild’s National Secretariat, to other branches of the Guild, to the Guild’s and the Branch’s related bodies corporate, and to agents, contractors service providers and partners engaged by the Branch or the Guild to provide the Services. The Branch will not otherwise use or disclose your Personal Information, unless you have given consent, or the Branch is authorised or required to do so by law. For more information about how the Branch and the Guild handles your Personal Information, how you can request to access, correct or update the Personal Information the Branch holds about you, and who to contact if you have a privacy enquiry or complaint, please see the Guild’s Privacy Policy on the website www.guild.org.au. If you elect not to provide your consent to any or all of the uses or disclosures of your Personal Information proposed in this Form, we may be unable to process your membership application and/or provide the Services to you. You can also withdraw your consent at any time, by just letting us know.

PRIVACY COLLECTION NOTICE

By submitting this completed application Form, you acknowledge that your personal information including your name, address, phone number and email address (Personal Information) is being provided to The Pharmacy Guild of Australia, Victoria Branch, ABN 35 603 508 734. The Personal Information you provide will be used by the Branch to administer and manage your membership, and to keep you informed about developments in the practice of pharmacy, and to send you marketing material about associated products, offers, services and events relating to community pharmacy (Services). The Branch is a branch of The Pharmacy Guild of Australia ABN 84 519 669 143 (the Guild) and, as such, may disclose your Personal Information to the Guild’s National Secretariat, to other branches of the Guild, to the Guild’s and the Branch’s related bodies corporate, and to agents, contractors service providers and partners engaged by the Branch or the Guild to provide the Services. The Branch will not otherwise use or disclose your Personal Information, unless you have given consent, or the Branch is authorised or required to do so by law. For more information about how the Branch and the Guild handles your Personal Information, how you can request to access, correct or update the Personal Information the Branch holds about you, and who to contact if you have a privacy enquiry or complaint, please see the Guild’s Privacy Policy on the website www.guild.org.au. If you elect not to provide your consent to any or all of the uses or disclosures of your Personal Information proposed in this Form, we may be unable to process your membership application and/or provide the Services to you. You can also withdraw your consent at any time, by just letting us know.

PRIVACY COLLECTION NOTICE

By submitting this completed application Form, you acknowledge that your personal information including your name, address, phone number and email address (Personal Information) is being provided to The Pharmacy Guild of Australia, Western Australia Branch, ABN 56 917 919 584. The Personal Information you provide will be used by the Branch to administer and manage your membership, and to keep you informed about developments in the practice of pharmacy, and to send you marketing material about associated products, offers, services and events relating to community pharmacy (Services). The Branch is a branch of The Pharmacy Guild of Australia ABN 84 519 669 143 (the Guild) and, as such, may disclose your Personal Information to the Guild’s National Secretariat, to other branches of the Guild, to the Guild’s and the Branch’s related bodies corporate, and to agents, contractors service providers and partners engaged by the Branch or the Guild to provide the Services. The Branch will not otherwise use or disclose your Personal Information, unless you have given consent, or the Branch is authorised or required to do so by law. For more information about how the Branch and the Guild handles your Personal Information, how you can request to access, correct or update the Personal Information the Branch holds about you, and who to contact if you have a privacy enquiry or complaint, please see the Guild’s Privacy Policy on the website www.guild.org.au. If you elect not to provide your consent to any or all of the uses or disclosures of your Personal Information proposed in this Form, we may be unable to process your membership application and/or provide the Services to you. You can also withdraw your consent at any time, by just letting us know.