Title (Mr/Ms/Dr/Prof etc):
Surname:
Given names:
School:
Position:
Mail Delivery Point:
Telephone:
Mobile:
Your email:
Date of Birth:
Gender:MaleFemalePrefer Not To Say
Home address:
Postcode:
Suburb:
Mode of Employment: Teaching OnlyResearch OnlyResearch/TeachingOngoingFixed Term ContractFull TimePart Time
Date Of Expiry
Hours P.W Or %
Salary Level: ABCDE Staff Payroll Number (If Known):
I hereby apply for membership of the UWA Academic Staff Association and I authorise UWA to deduct from my salary by regular instalments.
Signed:
Date:
I agree the Membership Terms and Conditions
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