PLEASE COPY/PRINT APLICATION AND RETURN TO THE ABOVE ADDRESS
I am requesting admission as (please tick grade):

  Fellow (complete sections 1, 3, 4, 5, 6)	  Undergraduate Student (complete sections 1, 2, 6)
  Member (complete sections 1, 3, 4, 6)		  Subscriber (complete sections 1, 6)
  Graduate (complete sections 1, 3, 4, 6)
  Associate (complete sections 1, 3, 4, 6)
_____________________________________________________________________________________________
1.	ALL APPLICANTS (PLEASE PRINT IN BLOCK CAPITALS)

Family Name:	________________________________________  Title :   _______________Gender (M/F) _____

Given Names :    ________________________________________  Date of Birth:  __________________________

Address:  _____________________________________________________________________________________ 

____________________________________________________________________Postcode:   _______________

Home Tel.:  ______________________________ Business Tel.: ________________________________________ 

Fax:  _______________________________ e-mail:  __________________________________________________

_____________________________________________________________________________________________
2.  	UNDERGRADUATE STUDENTS ONLY

Tertiary Institute:  _____________________________________________________________________________

Degree Course:  _______________________________________________________________________________

Verification by member of staff:

I certify that the abovenamed person is a student of Physics at this Institute/University, undertaking a degree which can lead to a Physics major and recommend him/her for admission as a Student member of the Australian Institute of Physics.

							GAIP	
Signature:  _______________________________________  	MAIP   Name:  _________________________
							FAIP     (Block capitals)

_____________________________________________________________________________________________
3.	ASSOCIATES, GRADUATES, MEMBERS, FELLOWS

Degree(s) held (with major(s) year(s) of Graduation):   
Conferring Institute(s)/University(ies):

Qualifications	Year of Completion	Institute(s)/
University(ies)	Major

				

Current Employer:   ____________________________________________________________________________

Position Held:  ________________________________________________________________________________

PLEASE ATTACH:
(1)	An official transcript of academic record.
(2)	Curriculum Vitae which includes a statement of employment history since graduation.
(3)	List of publications, patents, or other evidence of professional standing appropriate to the
	level of membership being applied for.

_____________________________________________________________________________________________
4.	STATEMENT BY PROPOSER:

(The proposer should be a member of the Institute in a grade at least equivalent to that sought by the applicant.  Applicants for Associate membership may also approach a person in a position of authority (e.g. school principal)).  With application the grade of Fellow, proposers and supporters may be requested to provide confidential written supporting references.

I am acquainted with the applicant’s career in Physics and propose him/her for admission to the grade of  ∑Associate ∑Graduate ∑Member ∑ Fellow of the Australian Institute of Physics.

							GAIP	
Signature:  _______________________________________  	MAIP   Name:  ______________________________
							FAIP     (Block capitals)

Associates, Graduates and Members:  Please complete section 6 below.

_______________________________________________________________________________________________________
5.	STATEMENT BY SUPPORTER (applicants for Fellow only):

As a Fellow of the Institute, I acquainted with the applicant’s career in Physics and propose him/her for admission to the grade of Fellow of the Australian Institute of Physics.

Signature:  _______________________________________  	FAIP    Name:  ______________________________
						    	            (Block capitals)

_______________________________________________________________________________________________________
6.	DECLARATION BY APPLICANT  (all membership categories)

If admitted to the Australian Institute of Physics, I agree to be bound by the by-laws and rules of the Institute and will advance the objects of the Institute so far as is in my power.

Signature:  ______________________________________________  	Date:  ______________________________