Application Form for Membership and/or Accreditation of the Australian Mathematical Society

1. PERSONAL DETAILS (Please print or type)


Surname: ............................................................

Other names: ........................................................

Title: ........

Degrees and/or Diplomas: ............................................

Current position or occupation: .....................................

Employer: ...........................................................

Address for notices and publications (incl. Institutional members):

   ..................................................................

   ..................................................................
   
   ............................................Postcode: ............

Phone: ..............................  Fax: .........................

Email: ..............................................................


2. MEMBERSHIP REQUESTS (Please circle the appropriate responses)


I wish to join ANZIAM:                 YES                     NO

I request reduced-rate membership:     YES (see 4. below)      NO

I request reciprocal membership:       YES (see 5. below)      NO

I wish to be a Sustaining Member:      YES                     NO

I wish to become a Life Member:        YES                     NO

I wish to become an Education Member:  YES                     NO

Institutional Membership is required:  YES (see 8. below)      NO


3. DECLARATION

I hereby declare that I accept the obligations of membership of the
Australian Mathematical Society, to further and foster the aims and
objectives of the Society and to abide by the Constitution of the
Society.

Date: .................  Signature: ...............................


Proposal

I, being a member of the Society, propose and recommend the above
person for membership of the Society.

Name (block letters): ......................................


Signature: .............................................

Note: If required, the Treasurer can sign this proposal.



4. APPLICATION FOR REDUCED-RATE MEMBERSHIP

I hereby apply for the reduced-rate annual subscription for the year
ended 31 December ..... . I submit the following supporting statement
for the information of the Council of the Australian Mathematical
Society only, and note that I do not qualify for reciprocal membership
of other societies while on reduced rate.

I am at present in the ....... year of my course for the degree of

........................... at ....................................

The grounds for my application (if other than the above) are

...................................................................

...................................................................


Date: .................  Signature: ...............................

ENDORSEMENT

I, as a member of the Society having personal knowledge of the
applicant, certify that the above details are correct.

Name: .............................................................

Signature: ........................................................


5. APPLICATION FOR RECIPROCAL MEMBERSHIP


I hereby apply for reciprocal member of the Australian Mathematical
Society. I am at present a financial member of the

......................................................... (Society)

which has a reciprocity agreement with the Australian Mathematical
Society.

Date: .................  Signature: ...............................


6. QUALIFICATIONS AND EXPERIENCE

(This item must be completed by applicants for accreditation or for
a different level of accreditation.  For such applicants, THREE copies
of the application must be submitted. Other applicants for membership
should go to Section 8 below.)

I wish to apply for accreditation with the Australian Mathematical

Society as (Tick one):

 __
|  |  A GRADUATE MEMBER (allowing the postnomials GAustMS)
 --
 __
|  |  An ACCREDITED MEMBER (allowing the postnomials MAustMS)
 --
 __
|  |  A FELLOW (allowing the postnomials FAustMS)
 --

If not applying concurrently for membership of the Society: 

  I have been a member of the Society since ...........



QUALIFICATIONS

Degree, diploma, etc.        University/College                 Year

.....................................................................

.....................................................................

.....................................................................

.....................................................................

(NOTE: Documentary evidence may subsequently be requested.  The
Accreditation Committee is empowered to request applicants whose
qualifications are not from an Australian institution to undertake an
examination.)


PROFESSIONAL EXPERIENCE

Present position and responsibilities: ..............................

.....................................................................

.....................................................................

.....................................................................

............................. Position held since ...................

Previous positions (Name of employer must be given and mathematical
aspects must be described for all positions in government and
industry. 

   Position, Duties, etc.                               From     To

.....................................................................

.....................................................................

.....................................................................

.....................................................................

.....................................................................

.....................................................................


OTHER INFORMATION that may be useful to the Accreditation Committee
(Optional)

.....................................................................

.....................................................................

.....................................................................

(NOTE: The applicant may forward any other material for the
Committee's consideration.)



7. REFERENCE AND DECLARATION

I have asked the following person send a reference:

.....................................................................

Address/Email: ......................................................

.....................................................................



I understand that no part of the accreditation fee is refundable,
whether or not the application is successful.  I understand that, if
the application is successful, the use of the postnominals is
permitted only while I remain a member of the Society, and while I
continue to satisfy the occupational requirements described in the
Constitution of the Society.

I confirm that the information given by me in this application is
accurate.

Date: ...............  Signature: ..................................



8. INSTITUTIONAL MEMBERSHIP

Our institution, .................................................

hereby requests Membership of the Australian Mathematical Society
as an Institutional Member.

Name/position of authorising officer: ............................

..................................................................

Signature: .................................   Date: .............


(Use section 1. above to provide a mailing address.)


9. PAYMENT

The total sum for subscription for the current year and for accreditation is

$..............

EITHER:

1. I enclose a cheque for $....... made out to the Australian

   Mathematical Society.

OR:

2. Please debit my (circle one):

   Mastercard      Visacard       Bankcard     American Express


   Card number: __ __ __ __  __ __ __ __  __ __ __ __  __ __ __ __

   Card Expiry Date: .............................................

   Card Holder Name: .............................................

   Signature: ........................... Date: ..................
   
   Amount: AU$.............