ATANZ MEMBERSHIP APPLICATION FORM
FOR THE YEAR ENDED DECEMBER 2008

Membership application - PERSONAL
Please complete this section if the Membership is being paid by you. 
Please provide your personal billing details not that of your employer

Surname: 		First Names:	
Postal Address:	
Ph-Home:		Mobile: 		E-mail:	
Membership application – ORGANISATION
Please complete this section if the Membership is being paid by your employer for membership in your name. 
Full billing details for the organisation are required

Organisation:	
Surname: 		First Names:	
Postal Address:	
Ph-Work:		Mobile: 		Fax:	
E-mail:	

QUALIFICATIONS

Organisation/Employer: 	
Profession/Position Held: 	
Professional Qualifications:  	

* NOTE: For the purposes of ATANZ, assistive technology is defined as “any item, piece of equipment or product system whether acquired commercially off the shelf, modified or customised that is used to increase or improve functional capabilities of people with disabilities” (Cook and Hussey)

* An Assistive Technology Practitioner is defined as one or more of the following:
o An Accredited Assessor under the Ministry of Health scheme 
o An ACC approved Assistive Technology assessor and/or provider 
o A member of a related professional body eg speech-language therapist, occupational therapist, teacher, psychologist) working or seeking to work in Assistive Technology service provision. 
    (please specify professional body__________________________)


* An Associate Member:
o Individuals who market/supply Assistive Technology equipment/solutions.
o Families and Assistive Technology users

These criteria are a guide only. The Trustees reserve the right to evaluate appropriate membership on a case by case basis.

Are you an ‘Assistive Technology Practitioner’ as defined above?	YES ?          NO??


Please make cheque payable to ‘ATANZ’. Registrations should be posted to: ATANZ, c/- TalkLink Auckland, PO Box 44053, Pt Chevalier, Auckland

	?Practitioner Membership		$70.00 plus GST ($78.75 inc)

	? Associate Membership*		$50.00 plus GST ($56.25 inc)  * Please note that Associate Membership is non-voting.

	? Student Member			$35.00 plus GST ($39.38 inc)

Please forward any queries to ann.smaill@talklink.org.nz Copies of the ATANZ Trust Deed are available from www.atanz.org.nz


ASSISTIVE TECHNOLOGY ALLIANCE NEW ZEALAND TRUST INCORPORATED