MLSV - Nomination Form

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Membership nomination

Membership of the Medico-Legal Society of Victoria is open to legally-qualified members of the medical and of the legal professions.

Prospective members require the consent of two current members as nominators in order to join.

Prefer to use mail?

Use the paper form

Nominee Details

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* Title

* First & Last Name

* Mobile Phone

Alternate Phone

* Your E-Mail Address

a confirmation email will be sent to you at this address

Your Website

* Subscription

Annual Membership Subscription 2018 / 2019 (Incl. GST) sign up $75.00 for 6 months Subscription to the Medico – Legal Society of Victoria runs by financial year. Payment of $150.00 (inc GST) is payable prior to nomination. If nomination occurs after December 1 payment of $ 75.00 (inc GST) is payable.

If your application is not successful your payment will be refunded.

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Mailing Address

* Street

Street (Second Line)

* Suburb

* Country

* State

* Post Code

Address Line 3

* What profession(s) are you part of?

Medical
Legal

Your name will be listed in our member directory. Please tick which contact details you would like listed in the directory

Phone Number
Alternative Phone
Email
Mailing Address

* Choose a Password

must be 6 or more characters

* Confirm your Password

Details of Nominators

Name of Nominator 1

Email of Nominator 1

Name of Nominator 2

Email of Nominator 2

Agreement

I have contacted my nominators and I confirm that they agree to support my application
I have read the Constitution & I agree to abide by it

Email Nominators for confirmation