Application for Membership (Please print or type) Dr./Mrs./Miss/Mr. Surname:....................................................................................................... Given names:.............................................................................................................................. Business address:.................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... Postcode:.................... Telephone: (___)............................... Fax: (___)............................... Home address:........................................................................................................................... Postcode:.................... Telephone: (___)............................... Fax: (___)............................... Preferred address for all communications: ___[__] Home______[__] Business Current position:......................................................................................................................... Job Description:.......................................................................................................................... ........................................................................................................................................................ ........................................................................................................................................................ Academic qualifications (please attach copy of certificates).............................................. ........................................................................................................................................................ Course of study & Institution (students only).......................................................................... ........................................................................................................................................................ Previous experience in science communication................................................................. ....................................................................................................................................................... Previous experience in related fields:.................................................................................... ....................................................................................................................................................... Life sciences publications / papers presented (please attach copy of titles):............... ....................................................................................................................................................... Membership in other professional institutes / societies:................................................... ....................................................................................................................................................... Honours and awards............................................................................................................. ....................................................................................................................................................... I.(name)................................................................wish to apply for membership of the Institute and agree to abide by the A.I.M.B.I. Constitution and By-Laws. Signature of applicant:............................................................................................................... Please send cheque for $.................. made payable to AIMBI(......................)(state) with your application. This amount being the National Joining Fee will be refunded if you are unsuccessful. We, being current financial Professional A.I.M.B.I. members, nominate and second the applicant in the belief that the applicant will be worthy of membership of the institute. Nominated by:................................................Signed:.............................................................. Seconded by:..................................................Signed:.............................................................. State Executive Use Only Received by:......................................................................................Dated:........................... Action Plan 1. Executive Committee has [__] Approved______[__] Disapproved. Any comments from committee?............................................................................................... ................................................................................................................................................ 2. Has the applicant been informed about the comments from the State Executive?_[__] Do not continue if applicant has been disapproved. 3. Has the original membership been sent to the Registrar? _[__] 4. Has the National Joining Fee & Dues been sent to the National Treasurer? _[__] Dated (Official joining date):............................................................... State Group/Branch: NSW [__]; QLD [__]; SA [__]; Vic. [__]; WA [__]. Level/Grade: Professional [__]; Affiliate[__]; Student [__]; Corporate [__]. Categories: Photography [__]; Art [__]; Audio Visual [__]; Management[__]; Computer Graphics[__]; Academic [__]; Registrar Use Only Certificate Number:.............................................................................Dated:........................... Has the certificate been sent to the calligrapher?_[__] When.................................................. Any comments?......................................................................................................................