Application Form for Accreditation with the Australian Mathematical Society

Dr A. Howe

Treasurer, Australian Mathematical Society

Department of Mathematics

Australian National University

ACT 0200

Australia.

treasurer@austms.org.au

We regret that we are not yet able to handle secure transmission of credit card details. If you are submitting the information below electronically, please ensure that the appropriate fee is sent at the time of submission (See below).

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:

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

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

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

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


2. QUALIFICATIONS AND EXPERIENCE

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 ...........

(NOTE: To be accredited as a Fellow, it is necessary to have been an
Ordinary or Sustaining Member for at least three years.)


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.)


I have asked the following person send a reference:

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

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

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



DECLARATION

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: ..................................

PAYMENT

The sum payable 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$.............