CPCA Membership Application

Membership Fee: $825.00 (GST Inclusive) – Paid on application.
Click here to view the Membership Information Booklet.
Your application is subject to approval/acceptance by the Membership Committee.
Please allow up five business days for a response. Thank you.

Type of Applicant
Type of Applicant*
Please select ONE from the list below:
- I am a medical student
- I am a registered medical practitioner
- I hold a Fellowship in aesthetic/cosmetic medicine - Medical Practitioners who hold a fellowship in aesthetic/cosmetic medicine may apply for equivalence recognition and be considered eligible for CPCA Fellowship.
How did you hear about the CPCA?*
Select an option from the drop-down list below.
Applicant's Details
Personal details must match the record contained within AHPRA Medical Register. Click HERE to check.
Current Medical Registration No. (in full)*
Title*
First Name*
Middle Name
Last Name*
PRIMARY CONTACT DETAILS
These details are NOT published anywhere.
Mobile Phone #*
Business Phone #
Preferred Email Address*
Re-enter Email Address*
Organisation
If applicable.
Address Line 1*
Address Line 2
SUBURB*
STATE*
COUNTRY*
POSTCODE*
Image of passport or Australian drivers licence for ID purpose*
Accepted file types: jpg, png, pdf, gif, Max. file size: 5 MB.
Head & Shoulders Photograph*
Processing of application may be delayed where this is missing. Do not go to any expense. This image will NOT be published anywhere.
Accepted file types: jpg, png, pdf, gif, Max. file size: 5 MB.
MEMBERSHIP FEE PAYMENT - $825.00
Receipt and paid tax invoice will be provided via return email.

Payment options:

Option #1: Credit card payment
Visa or Mastercard only. American Express is not accepted.
Provide card details below.
Please tick the box below if you want to pay via credit card.
- I will pay via credit card
Membership Fee + Credit Card Payment Fee (1.8%)
$825 + $14.85 = $839.85 Inclusive of GST
Price: $ 839.85
Total
Membership fee + credit card payment fee
$ 0.00
Credit Card
Card Details
Cardholder Name
Option #2: Bank Transfer
BSB # 306-089
ACCT # 343-239-3
NAME: Cosmetic Physicians College of Australasia
Bank Transfer Payment Number/Receipt Number:
If you paid via bank transfer, please provide bank processing reference number here and upload bank transaction receipt below.
Upload bank transaction receipt
Accepted file types: jpg, png, pdf, gif, Max. file size: 5 MB.
Applicant's Declaration
Please provide signed declaration form that can be found HERE. Thank you.
Upload Applicant's Declaration*
Accepted file types: jpg, png, pdf, gif, Max. file size: 5 MB.
Please ensure that you have answered all the required fields and uploaded all the required documents before clicking the "Submit" button.
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CPCA Membership Application

Type of Applicant

Applicant's Details

PRIMARY CONTACT DETAILS

MEMBERSHIP FEE PAYMENT - $825.00

Payment options:

Option #1: Credit card payment

Option #2: Bank Transfer

Applicant's Declaration

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