Title

First name

Last name

Gender

Password (minimum of 6 characters)

Password confirmation

Please upload a recent passport style photo:

Address

Suburb

Australian state

Postcode

Mobile phone

Home phone

Website

Dob

Would you like to receive regular news and important updates via email?

Yes No

Would you like to receive regular news and important updates via sms?

Yes No

I wish to receive my AMT quarterly journal electronically

Yes No

I would like to be involved with AMT and offer to volunteer assistance if needed.

Yes No

Application Fee. This is a non-refundable fee, which must be sent with your Application :

$20.00

Paying via Credit Card?

Yes No

Name on Credit Card

Credit Card Number

Security Code on Card (CVV)

Card Expiration

Expiration (MM/YYYY) /

New Application