To apply for Membership of the MSIA, complete this form and send to the MSIA - ceo@msia.com.au  or post to the address below. Please note this form will be forwarded to the MSIA Committee for consideration. Once approved an invoice will be sent to you.  All members of the Association must have medical software products or services and abide by the Objectives, Code of Practice, Duties of Representatives and MSIA Representation, and the Policy on Data Ownership and Access.  The guidelines may be found on the MSIA website page entitled 'About Us' and 'Rules of Association' at http://www.msia.com.au/

Please 'click here' to obtain a copy of the application form in MS Word format.

APPLICANT ORGANISATION NAME & ABN ________________________________________________________________________

As an authorised senior executive of this organisation, I would like to apply for this organisation's membership of the Medical Software Industry Association at an annual subscription fee of $1100+GST for organisations with 10 employees or more and $900+GST for organisations with nine employees or less and $450+GST for sole traders / consultants and pro rata thereof (as applicable) for the calendar year 1st January to 31st December, 2010.

Does any current MSIA member have a controlling interest in your organisation?   Y/N  (If Yes, Please Specify).

____________________________________________________________________________________________________

Title and Name of Nominated Representative:________________________________________________________________________

Type of  Medical Software Business: ________________________________________________________________________________

Medical Product or Service Name:___________________________________________________________________________________

Number of Employees in the Organisation _________________________________________________________________

Short Description of Medical Software Product/Service:______________________________________________________________

Business Address:  ________________________________________________________________________________________________

Business Phone: ______________________________________ Fax:____________________________________________   

Mobile:______________________  Email address for MSIA website: __________________________________________________

Email addresses for MSIA discussion forums:________________________________________________________________________

Applicants Website Address: ____________________________________________________________________________

Signature: ________________________________________________________________________________________________________

Name (block letters):______________________________________________________________________________________________

Date:_____________________________________________________________________________________________________________  

The MSIA is a GST registered organisation

ABN 82 324 598 961