Application for Membership

Title*
If other - specify
First Name*
First Name
Surname*
Surname
Address*
Street Address Address Line 2 City State Postcode Country
Private Email (Not for Publication)*
Telephone (Private)
Date of Birth*
DD slash MM slash YYYY
Preferred Name for Membership Certificates*
If accepted for membership I authorise the listing of my name, employer and contact details on the AICLA website (www.aicla.org):*
- Yes
- No

Company Name*
Position / Title*
Business Postal Address*
Street Address Address Line 2 City State Postcode Country
Telephone (Business)
Mobile
Email*
Date Employment Commenced*
DD slash MM slash YYYY

1) If less than 5 years with this employer specify details of previous employment over a 5 year period.
Employer Name/s Start Period of Employment End Period of Employment Position held
2) Previous history of employment as a Loss Adjuster (if not shown above).
Employer Name/s Start Period of Employment End Period of Employment Position held

University Qualifications (if any)
Name of institution Year Qualifications
Trade/Technical Qualifications (if any)
Name of institution Year Qualifications
Professional Bodies Membership (if any)
Name of institution Year Qualifications / Level of Membership
Upload copies of education and professional qualification certificates (if any)
Drop files here or

Max. file size: 64 MB.
Have you previously been a member of AICLA?*
- Yes
- No
Period From
DD slash MM slash YYYY
Period To
DD slash MM slash YYYY

Please supply full details of any interests, directly or indirectly, that you and/or your spouse/partner and/or your business partner/ directors have in any other professional, commercial or trade practice or business as a principal, director, partner, employee, agent or shareholder other than in a listed public company. (Including building and cleaning contractors, furnishers, motor vehicle repairers.)*

Please Ensure the Following Items Accompany this Application

Employer Name/s	Start Period of Employment	End Period of Employment	Position held

Employer Name/s	Start Period of Employment	End Period of Employment	Position held

Name of institution	Year	Qualifications

Name of institution	Year	Qualifications