The Cardiac Society of Australia and New Zealand (CSANZ)

Application for access to Med-E-Serv InTouch and CSANZ Members

CSANZ Members can register for access to the restricted CSANZ website services. Apply for access to the CSANZ Member Directory (access restricted to CSANZ Members) and to CSANZ Affiliate Member services (access restricted to CSANZ Affiliate Members).

Please complete the following details accurately:

Use the mouse or the Tab key to move between fields. Required fields are identified by a *.
Your username and password will be fowarded to the email address you provide below.

Title:

First Name:

Last Name:

Classification
Select One

Select your membership type

Position Title:

Organisation:

Business Address:

City/Suburb:

State:

Postcode:

Country:

Daytime Phone:

Email:

Primary Professional Affiliation:

You may submit three options for your preferred Username. Usernames must have no more than eight (8) characters - letters and numbers only! A suggested username would be your initial followed by the first 7 letters of your surname.

Preferred
Username 1:

Preferred
Username 2:

Preferred
Username 3:

Your application, if accepted, will entitle you to have access to the Med-E-Serv InTouch information service. You are also welcome to a complimentary listing in Med-E-Serv InTouch's People Directory if you complete the following input details. NB This Directory is not available on the public Internet, only to other registered InTouch users.

Mobile Phone:

Fax:

Are you a member of any other health related organisations? (eg. Special Societies)

Other Affiliation 1:

Other Affiliation 2:

Other Affiliation 3: