3.

Pelvic Pain Foundation of Australia Limited
Health Practitioner Subscriber Application

FAX TO: 08 8363 2911 EMAIL TO:

To be identified on the website of Pelvic Pain Foundation of Australia Limited ABN 98 168 910 316 (PPFA) as a health practitioner with an interest in the treatment of pelvic pain, you must be a Subscriber of PPFA. To apply to become a Subscriber of PPFA, you must complete this Application and submit it to PPFA.

This Application will become a Tax Invoice for GST purposes when full payment is made and this Application is accepted in accordance with the Terms and Conditions accompanying this Application. Please take a photocopy for your records.

Applicant’s details - please complete

Personal details
Full name:
Former name(s), if applicable:
Telephone: / Facsimile:
Mobile: / Email:
Practice details
Practice or trading name:
ABN:
Business address:
Postal address:
Do you have professional indemnity insurance in place for at least $5 million per claim? / Yes No
Registration details
AHPRA Registration No: / Registration expiry date:
Category:
Qualifications:
Area of interest:
Application or renewal and applicable fees (GST inclusive): / Application
Subscription:
1 year
3 years / $55.00 application fee
Plus:
$220.00 annual fee
$440.00 annual fee / Renewal
Subscription:
1 year
3 years / No renewal fee
$220.00 annual fee
$440.00 annual fee
Total price including GST: / $
Payment details
Card type: / MasterCard Visa / Name on card:
Card number: / Expiry date: / /
Security number: / Cardholder signature:

Your Application will not be considered by PPFA unless you have completed and signed this Application and payment of all application and subscription fees has been made or accompanies this Application.

In making this Application, the Applicant warrants that:

(a)  the information provided as part of this Application is true, complete and correct, and is not misleading; and

(b)  the Applicant has read, understood and agrees to be bound by the Terms and Conditions accompanying this Application.

Signed by the Applicant: ______Date: ______

Terms and conditions

The following terms and conditions (Terms and Conditions) apply to Your application to become a Subscriber of Pelvic Pain Foundation of Australia Limited (PPFA), or renew Your status as an existing Subscriber of PPFA. Where Your application is successful, these Terms and Conditions will apply to You whilst You remain a Subscriber of PPFA.

1.  Subscription

1.1  To be identified on the website of PPFA (www.pelvicpain.org.au) (Website) as a health practitioner with an interest in the treatment of pelvic pain, you must be a Subscriber of PPFA.

1.2  To qualify for acceptance as a Subscriber of PPSA (or to renew Your status as an existing Subscriber), You must:

(a)  submit a completed application form (in the form required by PPFA from time to time) (Application) with PPFA;

(b)  have a professional indemnity insurance policy in place for at least $5 million per claim;

(c)  hold a current AHPRA registration and must provide Your AHPRA registration number to PPFA; and

(d)  pay to PPFA the applicable application fee and/or subscription fee (Fees) using any of the accepted payment methods specified on the Application or Website at the time of payment.

1.3  PPFA shall consider Your Application following receipt of all documents and Fees as required by clause 1.2 and shall notify you in writing of the outcome of Your Application.

1.4  PPFA may, in exercise of its sole discretion, determine whether or not to accept Your Application. If PPFA decides not to accept Your Application, all Fees paid to PPFA by You will be refunded by PPFA.

1.5  If PPFA accepts Your Application, You will become a Subscriber of PPFA, and shall be entitled to the benefits in clause 2, for the term selected in Your Application, subject always to these Terms and Conditions.

2.  Display of Your details on the Website

2.1  As a Subscriber, You will be entitled to have the following details appear on the Website:

(a)  Your name, address and telephone number;

(b)  Your specialty or area of special interest in respect of the treatment of pelvic pain; and

(c)  such other details as PPFA may determine from time to time,

and You consent to the inclusion of those details on the Website by PPFA.

2.2  Without limiting clause 2, You acknowledge that PPFA may, include details on the Website in relation to PPFA seminars and affiliated programs that You attend or complete (as relevant).

3.  Ongoing obligations

3.1  You agree to promptly provide PPFA with such information and documents reasonably requested by PPFA from time to time to verify Your compliance with these Terms and Conditions.

3.2  You warrant that the information and documents provided by You to PPFA, whether in Your Application or otherwise, are true, complete and correct, and are not misleading.

3.3  Whilst You are a Subscriber, you must:

(a)  maintain a current AHPRA registration;

(b)  maintain professional indemnity insurance for at least $5 million per claim; and

(c)  promptly notify PPFA:

(1)  of the suspension, termination or expiry of Your registration with AHPRA;
(2)  of all matters that may otherwise impact upon the currency or scope of Your registration with AHPRA, including without limitation any notifications or other disciplinary action;
(3)  if you cease to maintain the insurance required by clause 3.3(b); and
(4)  any changes to Your details or other information appearing on the Website.

3.4  You acknowledge and agree that PPFA may cancel or suspend your subscription (and remove all of Your details from the Website) in its sole discretion, if:

(a)  You cease to hold an AHPRA registration;

(b)  You cease to maintain the insurance required by clause 3.3(b);

(c)  You are otherwise in breach of these Terms and Conditions; or

(d)  in the reasonable opinion of PPFA, Your continued association with PPFA may bring PPFA into disrepute, cause embarrassment for PPFA or otherwise invite criticism from other persons,

and the refund of any Fees paid by You in these circumstances will be at the discretion of PPFA.

4.  PPFA name and trade marks

You must not, without PPFA’s prior written consent, use PPFA’s name or any of PPFA’s trade marks in connection with any business, products or services.

5.  No representations or liability

5.1  You acknowledge and agree that PPFA does not represent or warrant that the Website will be accessible at all times, uninterrupted, error-free or defect-free. PPFA reserves the right, at any time, to disable, close or restrict access to the Website for security, privacy or other reasons giving rise to any risks for PPFA, or to enable the update of Website content.

5.2  To the maximum extent permitted by law, PPFA does not accept any liability for, and You hereby release PPFA from, any losses, costs, liability or expenses suffered or incurred by You arising out of or in connection with the availability of the Website or any error or defect in the Website.

6.  Indemnity

6.1  You acknowledge and agree that PPFA assumes no liability in connection with the display of Your details on the Website and that the display of Your details on the Website will be accompanied by a disclaimer to that effect.

6.2  You must indemnify PPFA for all claims, losses, costs, liability or expenses suffered or incurred by PPFA out of or in connection with the display of Your details on the Website.

7.  General provisions

7.1  A reference to “You” or “Your” in these Terms and Conditions means a reference to the Applicant named in the Application accompanying these Terms and Conditions.

7.2  Any waiver or relaxation, in whole or part, of any rights available to PPFA under these Terms and Conditions is only valid if it is in writing and is limited to the instance referred to in the writing.

7.3  If any provision of these Terms and Conditions is held to be invalid, unenforceable or illegal for any reason, it is to be read down to give it as much effect as possible, or if it is not capable of having any effect at all, it is to be severed from these Terms and Conditions, in which case, the remainder of these Terms and Conditions shall continue in full force.

7.4  These Terms and Conditions shall be subject to the laws of South Australia.

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