Applicant Details

NOTE: Fields marked an asterisk (*) are required/mandatory.

Organisation Name*
Contact Name*
Title*
Position*
Address*
Suburb*
Post Code*
Phone*
Email*
ACN / ABN*

Applicant Consent

I have read the Consent Declaration below*

As a member of Gippsland Health Network Limited, I agree to accept and abide by the terms of the Company’s Constitution. To view the full Constitution please visit our website: https://www.gphn.org.au/about-us/constitution*

Name of authorised organisation representative*

Position*

Date*

Consent Declaration

Gippsland Health Network collects personal information about members, necessary for managing the work of the Company and related programs. Such personal details will be handled by the Company staff in accordance with the Privacy and Confidentiality Procedure and Commonwealth and State privacy laws – Commonwealth Privacy Act (1988) www.privacy.gov.au & Victorian Health Records Act (2001) www.health.vic.gov.au/hsc


Membership Eligibility

Referring to Section 3 in the constitution, please complete the following:

Membership eligibility is for a person who engages in or has a legitimate interest in the provision of Primary Health Care within Gippsland (for example, by being involved in the delivery, coordination, management, or capacity building of Primary Health Care).

Primary Health Care means:

  1. services that are delivered in settings including general practices, community health centres, and allied health practices; and
  2. services that are delivered by health practitioners including general practitioners (GPs), nurses, nurse practitioners, allied health professionals, midwives, pharmacists, dentists and Aboriginal health practitioners.
  1. Please summarise your engagement or legitimate interest in the provision of Primary Health Care within Gippsland – less than 50 words*



  2. A person is eligible to become a Member if the person is one of the following – please select the applicable category*:
    1. a company registered under the Corporations Act or an incorporated association or other body corporate established or registered under another Act of Parliament, having either an Australian Company Number and/or an Australian Business Number
      Please select: YesNo
    2. an individual primary health care practitioner registered with AHPRA.
      Please select: YesNo
    3. an individual allied health practitioner registered with another health discipline registration body
      Please select: YesNo

Please tick all boxes.

Admission to membership

The Board will consider an application for membership within reasonable time after its receipt and determine, in its absolute discretion, the admission or rejection of the applicant.
The Board does not have to give reasons for accepting or rejecting an application.
captcha

Alternative method:

Downloadable PDF form. It can be completed online or it can be printed, completed and then either scanned and emailed back or posted back.

Online PDF Version