Practitioner Membership Application

Membership Application

New Member Details

First Name *

Last Name *

Postal Address *

Date of Birth *

City *

State *

Postcode *

Personal Phone *

Personal Mobile *

Personal Email *

Place of Birth

Nationality

Registration and Education

Where are you registered to practice? *

AHPRA Registration Number

Other Country

International Registration Number

Chiropractic & Other Educational Background

List your Academic Qualifications *

Institution

City / Country

Admission Date

Graduation Date

Degree / Diploma

Your Practice Details

Primary Clinic Details

Clinic Name *

Address *

City *

State *

Postcode *

Country *

Phone *

Email *

Website

Secondary Clinic Details

Clinic Name

Address

City

State

Postcode

Country

Phone

Website

How often do you use SOT?

Regularly

Sometimes

Rarely

Categories (I, II, III)

C.M.R.T.

Cranial

Do you have SOT Certification?

How many years have you been using SOT?

For ALL New Applicants.
Before your membership application can be approved by the SOTO Australasia Board of Directors, it must be endorsed by a current financial member of SOTO Australasia. If you don’t yet have a sponsor, please ‘find a practitioner’ or contact us for assistance.

SOTO Application Sponsor

Name & Address of a current SOTO Australasia member who will sponsor your application.

First Name *

Last Name *

Contact Number *

Clinic Address *

City *

State *

Postcode *

Your SOT History

Seminar

No of Attendances

Year of Most Recent Attendance

Country of Attendance

Introduction & Categories (I, II, III)

C.M.R.T.

Cranial

Advanced Modules

Membership Options

Please select your membership *

Full – Australian & New Zealand registered practicing chiropractors. ($290) Academic – Applies to retired, non-practicing chiropractors or practice hours under 10 hours a week. ($150) Associate – Applies to non-practicing chiropractic professionals working in conjunction with a SOT chiropractor. ($150) 1st Year Grad – Applies in 1st year of registering as a chiropractor. ($200) Overseas – Applies to chiropractors practicing outside of AU. ($120)

Declaration

I declare that the information provided is true and correct.

Typed Signature (Full Name) *

Signature Date