1 Year GPA Membership

Full name as it appears on the New Zealand Medical Register *

Date of birth *dd/mm/yyyy

Gender *

Home address *Full address including postcode

Contact phone number *

MCNZ number *

Nationality *

Ethnicity *

Current role in general practice * GP Fellow GP Registrar General Registrant not in training Overseas-trained doctor working in NZ Other PLEASE UPDATE

If you selected "Other", please specify (optional)

Current workplace(s) *

Do you own, or have shares/interests in a practice currently? * Yes No PLEASE UPDATE

Agreement (click to expand) * Yes No I agree to becoming a member of General Practitioners Aotearoa (GPA) and to receive communications by email regarding the organisation's activities. I understand that information supplied on this form is privileged and will not be shared with third parties without my permission. As a member, I agree to the rules of the organisation as set out in the constitution and understand that these rules may be amended at the organisations AGM from time to time. I agree to paying the membership fee, (for 2023 this is $95 + GST) or if my circumstances are constrained, and I am unable to pay the full amount, to contribute a koha as agreed by the incumbent board. I understand a tax invoice will be provided to me by email on receipt of my membership application, and issued annually thereafter to maintain membership. I understand that I can withdraw membership at any time by written notification.