Application Form for Accreditation with the Australian Mathematical Society
Please forward three copies of the form below, a reference, and payment of accreditation fees, to the Treasurer:- 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 ...........
QUALIFICATIONS Degree, diploma, etc. University/College Year ..................................................................... ..................................................................... ..................................................................... ..................................................................... (NOTE: Please attach a C.V. Other 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 should send a C.V. and may also 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 $....... made out to the Australian Mathematical Society. OR: 2. Please debit my: Mastercard Visacard Bankcard American Express Card number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Card Expiry Date: ............................................. Card Holder Name: ............................................. Signature: ........................... Date: .................. Amount: AU$.............