Membership Form

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Purpose*

I would like to join NZRDA for the first time

I have been a member before and would like to rejoin

I would like to renew my membership and/or pay my fees

I would just like to update my details

Which details would you like to update?*

Personal Details

Employment Details

Since my last membership renewal:*

My personal details may need to be updated - (address, mobile, etc)

My employment details may need to be updated - (run, designation etc)

My personal and employment details have not changed

I am choosing to rejoin because:*

Other reason for rejoining:*

Membership Number

Designation*

Employer*

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Employer if designation Trainee Intern

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Employer if designation Clinical Student

Specialty*

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Specialty

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Specialty

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Region

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Region

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Region

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Region

Location*

University of Otago

University of Auckland

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-------------------Workplace (if Te Whatu Ora)--------------------------------------------------

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Workplace Northland*

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Workplace Auckland*

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Workplace Waitematā*

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Workplace Manukau*

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Workplace Waikato*

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Workplace Bay of Plenty*

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Workplace Lakes*

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Workplace Taranaki*

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Workplace Tairāwhiti*

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Workplace Hawke's Bay*

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Workplace Midcentral*

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Workplace Whanganui*

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Workplace Wairarapa*

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Workplace Capital & Coast*

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Workplace Hutt Valley*

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Workplace Nelson Malborough*

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Workplace Canterbury*

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Workplace South Canterbury*

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Workplace West Coast*

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Workplace Southern*

Workplace*

Please fill out other fields.

Workplace UoA

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Untitled

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profession_if_employer_NZCPHM or private or RNZCGP

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profession_if_employer_TWO or UoO

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profession_if_employer_UoA

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profession_if_designation TI

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profession_if_designation Clinical Student

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professional title if_employer RNZCGP

Professional Title

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professional title if_designation_1st_Year_Public_Health_Registrar

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professional title if_designation_H/O

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professional title if_designation_SHO

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professional title if_designation_Trainee Intern

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professional title if_designation_Clinical Student

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professional title if_designation_Fellow

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professional title if_designation_Registrar

Professional Title*

What is your expected basic training graduation date?*

Are you commencing work at a future date?*

I am working now

I am yet to commence work

Future Work Commencement Date*

What year did you graduate?*

What year did you commence your GP Training?*

What year clinical student are you?*

Which medical school are you with?*

Otago

Auckland

Where are you currently placed?*

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Where are you currently placed?*

When do you expect to commence work as a House Officer?*

Medical Council Registration Number

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Medical Council Registration Number

Your Name*

Preferred / Alternative Name

Personal (non-work) Email*

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Mobile

NOT IN USE DUE TO COMMAS AND REMOVAL OF LEADING ZERO. INSTEAD USE TEXT FIELD WITH INPUT MASK AS PER NEXT FIELD (id 130) BELOW

Mobile*

Address*

Gender*

*The Registrar of Unions requires us to collect this data

Which most closely describes your ethnicity?*

You may select more than one:

Prefer not to answer

Māori

Pasifika

Pākehā / European

Asian

Hispanic, Latino or Spanish Origin

Middle Eastern

African

My ethnicity is not listed

Signature*

By writing your name below, you acknowledge you have read the terms above and give NZRDA the authority to act on your behalf:

Applicants who are yet to begin work*

You indicated above that you are commencing work at a future date. If this date is more than one month from today, please submit this form without payment. We will then be in touch closer to your work start date to request payment. Thank you!

My work commencement date is within a month from today

My work commencement date is more than one month from today

Payment Type*

-------------------Workplace (if Te Whatu Ora)--------------------------------------------------

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