Application for Membership

First Name *

Last Name *

Email Address *

Alternate Email Address

Contact Number

Preferred Address

Preferred Street Address

Preferred Suburb

Preferred State

Preferred Postcode

Alternate Address

Alternate Street Address

Alternate Suburb

Alternate State

Alternate Postcode

Membership Type *

Ordinary Member ($50.00)

Release of Details

I do not wish the Management 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.

Code of Ethics and Constitution of the Clinical Coders' Society of Australia Inc. *

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.

Date *

Legend (*) Mandatory Field

Only fill in if you are not human