Membership Application


If you are interested in becoming a CCSOFA please fill in the online form below. Or if you would prefer, download and complete the printed form.

Printed Membership Form

APPLICATION FOR MEMBERSHIP

Personal Details

Select Title:*
Surname:*
Given Names:*
Date of Birth: *
Gender: *

Primary Address

This is your preferred mailing address. Note that all correspondence will be forwarded to this address.

This is a HOME / WORK address: *
Address:*
Phone:*
Mobile:*
E-mail:*

Alternate Address

This is an alternate address which will be used if attempts to forward mail to you at your primary address fail.

This is a HOME / WORK address: *
Alternate Address:*
Alternate Phone:*
Alternate Mobile:*
Alternate E-mail:*

Type of Membership

I wish to join the CCSA as an:

(Applications for student membership need to be accompanied by proof of current enrolment in a recognised HIM / Clinical Coder education course)


RELEASE OF DETAILS**

I do not wish the Managing Committee of the CCSA to release my address details to organisations or companies approved by the Committee for distribution of relevant material, newsletters or advertising. I undertake to notify the CCSA in writing at such time as I wish to begin receiving advertising material.

(Please tick if appropriate) *

Agreement

I understand that by joining the CCSA I agree to be bound by the Code of Ethics and Constitution of the Clinical Coders’ Society of Australia Inc.

Electronic Signature (full name):
Date:

Payment

Upon review of application you will be invoiced for your membership by CCSOFA

Word Verification: