Optometry Australia

1) Declaration 2) Personal Details 3) Contact Details 4) Other Details 5) Review 6) Payment

Career Break Declaration

Career Break Membership is a highly-subsidised membership option for optometrists who are eligible for Ahpra registration and who are taking a complete break from, and not actively practising* in, or deriving income from, the optometry profession or industry in Australia for a minimum of 6 months.

Please complete all the sections and sign the form using your mouse/finger.

The purpose of my career break is: *

*Practising means any role, whether remunerated or not, in which the individual uses their skills and knowledge as an optometrist. Practice in this context is not restricted to the provision of direct clinical care.

Declaration
Please read the following terms carefully and tick all of them, as they define the Career Break Membership category:

Signature
Please sign to confirm that you understand and agree to the previous statements above.

Signature (sign in the box below)

Date Signed

In which state will you apply for.

Membership Category

Personal Details

Please use title case, e.g. (John Smith)

Title

First Name *

Middle Name

Surname *

Other Name/Preferred Name (for all correspondences) *

Gender *

Please describe your gender

Date of Birth *

Preferred Email *

Re-enter Preferred Email *

Have you been a member with us previously?

Are you of Aboriginal or Torres Strait Islander origin? *

Postal Address

Please use title case, e.g. (Optometry Australia)

Company/Practice Name

Position

Address line 1 *

Invalid value

Address line 2

Postcode *

Invalid value

Suburb *

State *

Invalid value

Primary Contact Details (Include Area Code)

Enter either Phone number or Mobile Number.

Phone Number (Landline)

At least one Phone Number is needed.

Mobile Number

At least one Phone Number is needed.

Fax

Email Address *

Primary Email has already been used

Website (Include http:// or https://)

Do you have a practice address?

Primary Practice Address (Australia Only)

Please use title case, e.g. (Optometry Australia)

Company/Practice Name *

Position *

Address Line 1 *

Address Line 2

Postcode *

Suburb *

State *

Phone(Landline) *

Mobile *

Fax

Email *

Website

Do you want to enter home address? (you must complete this if it is your preferred contact detail)

Home address

Please use title case, e.g. (Collin Street)

Address Line 1 *

Address Line 2

Country *

Postcode *

Suburb *

State *

Phone

Mobile *

Email *

Do you want to enter another address? (e.g. PO Box address)

Other address

Please use title case, e.g. (Collin Street)

Address Line 1 *

Address Line 2

Country *

Postcode

Suburb *

State

Phone

Mobile *

Email *

Fax

Preferred Contact Details (where you want your communications go to)

Home Address

Other Address

Review Your Application

You are about to submit the following details:

Career Break Reason

##careerbreakreason##

Personal Details

In which state is your primary practice located

##firstState##

Title

##title##

First Name

##first_name##

Middle Name

##middle_name##

Surname

##surname##

Preferred Name

##pref_name##

Gender

##gender## ##genderDescription##

Date of Birth

##dob##

Primary Email

##primary_email##

Have you been a member with us?

##is_member##

I am of Aboriginal or Torres Strait Islander origin.

##is_abo_tsi##

Primary Practice Address

Company/Practice Name

##primaryPracAddress_practiceName##

Position

##primaryPracAddress_position##

Address Line 1

##primaryPracAddress_addresslineone##

Address Line 2

##primaryPracAddress_addresslinetwo##

State

##primaryPracAddress_state##

Suburb

##primaryPracAddress_suburb##

Postcode

##primaryPracAddress_postcode##

Phone

##primaryPracAddress_phone##

Mobile

##primaryPracAddress_mobile##

Fax

##primaryPracAddress_fax##

##primaryPracAddress_email##

Website

##primaryPracAddress_website##

Home Address

Address Line 1

##homeAddress_addressone##

Address Line 2

##homeAddress_addresstwo##

State

##homeAddress_state##

Suburb

##homeAddress_suburb##

Postcode

##homeAddress_postcode##

Phone

##homeAddress_phone##

Mobile

##homeAddress_mobile##

##homeAddress_email##

Other Address

Address Line 1

##otherAddress_addressone##

Address Line 2

##otherAddress_addresstwo##

Country

##otherAddress_country##

Postcode

##otherAddress_postcode##

Suburb

##otherAddress_suburb##

State

##otherAddress_state##

Phone

##otherAddress_phone##

Mobile

##otherAddress_mobile##

##otherAddress_email##

FAX

##otherAddress_fax##

Preferred Contact Address

##preferred_contact_address##

Professional Information

Registration No

##professionalInfo_regno##

Upload Document

##professionalInfo_uploaddoc##

Are you Therapeutically Qualified?

##therapeutically_qualified##

Other Language 1

##professionalInfo_otherlangone##

Other Language 2

##professionalInfo_otherlanguagetwo##

Other Language 3

##professionalInfo_otherlanguagethree##

CPR Accredited

##professionalInfo_cpracc##

Child Safety Cert.

##professionalInfo_childsafertycert##

Compliance Consense

##professionalInfo_complianceconsent##

Qualification

First Qualification Name

##qualification_firstqualname##

Year Obtained

##qualification_firstDateObtained##

Institution

##qualification_firstinstitution##

Professional Information

##myAHPRARegoNumber##

Year First Qualified

##professionalYearQual##

Preferred option for meeting-related communications

I would like to continue to receive meeting-related communications

##meetCommFormat##

Opt In

Opt in to receiving printed correspondence from OA National eg. Optometry Connection magazine

##opt_inpubfromoa##

Opt in to receiving Third Party correspondence

##opt_inpubfromthirdparty##

Opt in to receiving correspondence from state office

##opt_inpubfromindividualstates##

Membership Type

##memType##

Total Amount

##totalAmt##

Code of Ethics

Payment Summary

You are paying for

Total

GST

Payment Method

YOU ARE PAYING FOR Membership Category :

Payment Frequency :

Payment Method :

Item Description

Amount(AUD)

Membership Renewal :

Administration Fee Instalment Payment

Total:

GST:

Amount to Pay:

Amount Still Owing (after pay):

By choosing the monthly payment option and clicking the SUBMIT NOW button, you are committing to pay your membership in instalments with the final payment due on the . If you choose to cancel or change your category of membership before , your state association staff will be able to advise whether any refund is applicable in the circumstances.
Please note that subsequent payments will be automatically processed on

Register for a Career Break Membership

Career Break Declaration

In which state will you apply for.

Membership Category

Personal Details

Are you of Aboriginal or Torres Strait Islander origin? *

Postal Address

Primary Contact Details (Include Area Code)

Do you have a practice address?

Primary Practice Address (Australia Only)

Do you want to enter home address? (you must complete this if it is your preferred contact detail)

Home address

Do you want to enter another address? (e.g. PO Box address)

Other address

Preferred Contact Details (where you want your communications go to)

Qualification

Professional Information

Preferred option for meeting-related communications

Opt in/out

Professional Information

Review Your Application

Personal Details

Primary Practice Address

Home Address

Other Address

Preferred Contact Address

Professional Information

Qualification

Services Provided

Equipment

Referees (Only required by Optometry Western Australia)

Professional Information

Preferred option for meeting-related communications

Opt In

Membership Type

Code of Ethics

Donation

Payment Summary

Payment Method

Select Name and Address to appear in the Invoice/Receipt