Thank you for your payment. You will receive notification of your payment details via email. To complete your membership application, please complete the form below. Title: ---Prof.Dr.Mr.Mrs.Ms.Miss. First Name: Surname: Organisation: Position: Name on credit card used to make payment (so we can match your membership with your payment): Postal Address: Post Code: Daytime Phone: Your Email: Membership Status: New MemberExisting Member The information below is optional but will help us to provide information and services that are appropriate to your needs. All information will be kept confidential. Your Age Group: ---Under 2020-2930-3940-4950-5960-6970-7980-8990+ Your Gender: ---MaleFemale Your Ethnicity: ---New ZealanderNew Zealand MaoriEuropeanAsianPacific PeoplesMiddle Eastern, Latin American & AfricanOther Are you currently undertaking study?: ---NoYes - full-timeYes - part-time Your Professional Area: ---AdministrationAllied healthArchitectureDentistryEducationGeriatric medicineLawMedical – otherNursingPharmacyPsychiatryPsychologySocial scienceSocial workOther Number of years working (or if a student, studying) in age related field: Your Work/Study Setting: ---GovernmentHospitalResidential CareCommunity CareCommunity Health CentreIndependent Research InstituteUniversityPrivate ConsultantCommercial SectorOther Current Field of Practice: ---Student undergoing studyAdministration – governmentAdministration – otherAllied health - physiotherapyAllied health – occupational therapyAllied health – otherEducationGeriatric medicine (inc. psychogeriatrics)Independent consultantMedicine – otherNursing – community careNursing – residential careNursing – otherResearchRetiredService provider – administrationService provider – direct careSocial workOther Sector Involvement: ---PrivatePublicNGO/CommunityEducationNot applicable Where did you hear about the NZAG: ---NZAG WebsiteConferenceNZAG MemberSearch EngineNewsletterOther Please enter the characters from this image into the field below: