Membership Application Form Membership Application ProcessPlease note this form will be forwarded to the MSIA Board for consideration. Once approved, an invoice will be sent to you. All members of the Association must have medical or health software products and abide by the Objectives, Code of Practice, Duties of Representatives and MSIA Representation, and the Policy on Data Ownership and Access. We ask that you have an existing MSIA member second your nomination, and should you not have a contact then please contact the Ceo@msia.com.au Should you have any comments or queries please contact the MISA Secretariat by emailing Secretariat@msia.com.auApplicant InformationMSIA Member seconding the Applicant Name Organisation email Post Title Organisation*ABN*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country PhoneEmail Website Qualifying InformationHow many staff do you have?1–56–2526–99100+Start-UpType of medical software business Aged Care Software Allied Health Software Billing Call Systems Care Planning Consulting Discharge Summaries Education Electronic Claiming Electronic Transfer of Prescriptions GP Software Hardware Hospital Software Integrated Care IT Support Medical Apps Medical Devices Medical Jewellery Medication Management Online Appointments Palliative Care Pathology Parent Education Personal Health Records Pharmacy Software Radiology Referrals Secure Message Delivery Shared Health Records Shared Health Record Repositories Specialist Software Telehealth Transcription Virtual Services Medical product/s or service name/sShort description of product serviceRepresentative InformationYour main representative will be the first point of call for all MSIA business, notices, invitations and account information.Name First Last Email PhoneMember NomineesEach member category is entitled to a minimum of 5 representatives to be included in all MSIA correspondence. Companies taking a 6 – 25 or 25+ membership type are encouraged to add more personnel by emailing firstname.lastname@example.org details of other staff members for inclusion.Nominee 1Name First Last Email PhoneNominee 2Name First Last Email PhoneNominee 3Name First Last Email PhoneNominee 4Name First Last Email PhoneNominee 5Name First Last Email Phone This iframe contains the logic required to handle Ajax powered Gravity Forms.