WVPHN Membership/Associate Application Form

Your details

Name*

Prefix First Last

Health Profession*

Practice Name

Address*

City*

Postcode*

State*

Is this address?

Contact phone number*

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Email*

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Acknowledgement

I wish to apply for Membership/Associate of Western Victoria Primary Health Network Limited. I understand that the Organisation is governed by a Constitution and that Membership/Associate is free. I understand the implications of being a Company Member/Associate as described in the Constitution, and undertake to inform the Company if my Member/Associate eligibility criteria changes. I am committed to working in an integrated primary care system in the Western Victoria region.

To view the constitution please click here.

Do you agree to the above?*

Yes, I agree

Membership category

I am eligible for membership in the following category:

A person who is a private practitioner practising in primary health care in the western Victoria Region who is registered with AHPRA who commits to working in an integrated primary care system.
Other persons

A copy of your AHPRA Registration is required

Accepted file types: doc, docx, pdf, Max. file size: 128 MB.

a) Allied health private practitioners who are recognised/registered by Medicare.
b) Qualified health professionals who are members of a professional association registered with Allied Health Professions Australia (AHPA).
c) Practice Managers
d) Other persons the Board may consider aligned to WVPHN and complies with the constitution

Please provide a copy of qualification and copy of registration with applicable body.

Max. file size: 128 MB.

Associate category (Non-member stakeholder)

Other non-health professionals providing support or services to Western Victoria PHN or primary care providers in this region

Please attach documentation to support your application.

Max. file size: 128 MB.

Your details

Acknowledgement

Membership category

Associate category (Non-member stakeholder)

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