NZISM - New Zealand Institute of Safety Management - NZ Institute of Safety Management

Please take a few moments to complete your application for membership.

This is an application for: *

	General Membership
	Student Membership
	Corporate Membership

First Name *

Surname *

Residential Address *

Residental Phone *

Mobile *

Email for communications *

Name of Business or Employer *

Postal Address *

Position Title *

Is this position full or part time *

(Corporate only) Nominated Contact Person - enter N/A for all other applications *

(Corporate only) Contact Person's Phone - enter N/A for all other applications. *

(Corporate only) Contact Person's E.mail - enter N/A for all other applications *

(Corporate only) List any other names from your organisation you wish to register for participation in NZISM activities - enter N/A for all other applications *

I/We undertake to ensure that the person/persons named in this application will abide by the NZISM Constitution and Code of Professional Behaviour. *

yes no

NZISM Branch (choose the branch that closest represents your location) *

Qualifications held in Occupational Health & Safety *

How long have you worked in the field of OH&S *

What is the main reason prompting you to join NZISM? *

Where did you hear about us? *

Other (please specify)

Membership Form