Application Form for Membership of the Australian Mathematical Society


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 (incl. Institutional members):

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

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

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

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

Mathematical Fields of Interest: ....................................

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


2. MEMBERSHIP REQUESTS (Please circle the appropriate responses)

I request Ordinary Membership:         YES                   NO

I wish to join ANZIAM:                 YES                   NO

I request reduced-rate membership:     YES (see 4. below)    NO

I request free student membership:     YES (see 4. below)    NO

I request Early Career Membership:     YES (see 5. below)    NO

I request reciprocal membership:       YES (see 5. below)    NO

I wish to be a Sustaining Member:      YES                   NO

I wish to become a Life Member:        YES                   NO

I wish to become an Education Member:  YES (see 5. below)    NO

Institutional Membership is required:  YES (see 8. below)    NO



3. DECLARATION

I hereby declare that I accept the obligations of membership of the
Australian Mathematical Society, to further and foster the aims and
objectives of the Society and to abide by the Constitution of the
Society.

Date: .................  Signature: ...............................


Proposal

I, being a member of the Society, propose and recommend the above
person for membership of the Society.

Name (block letters): ......................................


Signature: .............................................

Note: If required, the Treasurer can sign this proposal.




4. APPLICATION FOR REDUCED-RATE OR FREE STUDENT MEMBERSHIP

I hereby apply for the reduced-rate or free annual subscription for the year
ended 31 December ..... . I submit the following supporting statement
for the information of the Council of the Australian Mathematical
Society only, and note that I do not qualify for reciprocal membership
of other societies while on reduced rate.

I am at present in the ....... year of my course for the degree of

........................... at ....................................

The grounds for my application (if other than the above) are

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

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


Date: .................  Signature: ...............................

Student ID: ...............................

Tick one box:   Reduced     Free  (Gazette online only)

ENDORSEMENT

I, as a member of the Society having personal knowledge of the
applicant, certify that the above details are correct.

Name: .............................................................

Signature: ........................................................



5. APPLICATION FOR RECIPROCAL, EARLY CAREER or EDUCATION MEMBERSHIP


I hereby apply for Reciprocal, Early Career, or Education membership
of the Australian Mathematical Society. I am at present a financial 
member of the following society (or for Early Career, include a
photocopy of your PhD degree certificate):

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

(state Society with AustMS reciprocity agreement, AAMT or MERGA)

Date: .................  Signature: ...............................



6. INSTITUTIONAL MEMBERSHIP

Our institution, .................................................

hereby requests Membership of the Australian Mathematical Society
as an Institutional Member.

Name/position of authorising officer: ............................

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

Signature: .................................   Date: .............


(Use section 1. above to provide a mailing address.)



7. GAZETTE

How do you want to receive the Gazette?

I'll read it online.         
Please send a paper copy.   




8. PAYMENT

The total sum for subscription for the current year 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$.............

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