Registration
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I wish to register as a member of the Victorian eHealth Network.

The Victorian eHealth Network is a forum to promote and support Victoria’s eHealth industry through information exchange; peer-to-peer networking; product and service demonstrations; collaboration opportunities; research knowledge exchange; export support; and dissemination of Government information related to eHealth.

The data you provide about yourself and your organisation will be used within the network to facilitate inter-communication between members and to cultivate the eHealth industry in Victoria. Your company profile and contact information will be published on the website and progressively be made available so that people wishing to use your services can find your business and contact you.

New members require a proposer and a seconder. We will arrange someone for you on receiving your application.

To join the Network please complete and submit the form below.

NOTE: For organisation memberships, please send to enquiries@ehealthvic.org.au a list of contacts and email addresses of those whom you would like to receive VEHN newsletters (up to 5 additional contacts for small organisations; up to 14 for large organisations).

* This Field is required This Field IS visible on profile Information for: Membership Type : <p>For organisation memberships, please send to <a href="mailto:enquiries@ehealthvic.org.au">enquiries@ehealthvic.org.au</a> a list of contacts and email addresses of those whom you would like to receive VEHN newsletters (up to 5 additional contacts for small organisations; up to 14 for large organisations).</p>
* This Field is required This Field IS visible on profile Information for: Company Name (or workplace name for Individual membership) : <p>Please provide the name of the company you represent</p>
* This Field is required This Field IS visible on profile Information for: Name : Please enter your real full name.
This Field IS visible on profile Information for: Address : <p>Please provide the physical address of the company you represent.</p>
This Field IS visible on profile Information for: City/Suburb : <p>Plesae provide your City or Suburb</p>
This Field IS visible on profile Information for: State : <p>Please select from the state options</p>
This Field IS visible on profile Information for: Postcode : <p>Please provide your Postcode</p>
This Field IS visible on profile Information for: Telephone : <p>Please provide your landline phone number</p>
This Field IS visible on profile Information for: Mobile : <p>Please provide your mobile number</p>
* This Field is required This Field IS NOT visible on profile Information for: Email : Please enter a valid e-mail address. A confirmation email will be sent to this address upon registration.
* This Field is required This Field IS visible on profile Information for: Username : Please enter a valid username.  No spaces, at least 3 characters and contain 0-9,a-z,A-Z
Your password will be sent to the above e-mail address.
Once you have received your new password you can log in and change it.
* This Field is required This Field IS visible on profile Information for: Website : <p>Please provide your company website address, for example: www.mycompany.com.au</p>
* This Field is required This Field IS visible on profile Information for: What does your organisation do? : <p>Please provide some details regarding your company - this could be from the 'About" section of your website, or the company boilerplate for press releases</p>
* This Field is required This Field IS visible on profile Information for: What are your organisation's main eHealth capabilities/solutions? : <p>Please select an option, if you select 'Other' then please add further details in the next field</p>
This Field IS visible on profile Information for: Specify your other capability/solution : <p>Please fill this field if you have selected 'Other' in the previous question</p>
This Field IS visible on profile Information for: Where do you currently offer your eHealth solutions? : <p>Please select an option, if you select "Overseas' please add further details in the field below</p>
This Field IS visible on profile Information for: Specify overseas locations : <p>Please fill this field if you have selected 'Overseas' in the previous question</p>
This Field IS visible on profile Information for: What type of organisation are you? : <p>Please indicate the type of organisation that best suits your company - If you select 'Other' please add further details in the field below</p>
This Field IS visible on profile Information for: Specifiy your other organisation type : <p>Please fill in this field if you have selected 'Other' in the previous question</p>
* This Field is required This Field IS visible on profile Information for: What is the approximate size of your organisation? : <p>Please select from the option list</p>
This Field IS NOT visible on profile Information for: What is the annual revenue of your organisation? : <p>Please provide an approximate annual turnover in Australian dollars - this information is used for internal reporting only</p>
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Please post or fax cheques to:
Victorian eHealth Network

300 Huntingdale Road
Huntingdale VIC 3166
+61 3 8610 1936 or
+61 3 9545 6708

EFT: (for international EFT payments, please contact us first)
BSB: 033-090
Account No.: 405001
Account Name: Victorian eHealth Network
Please put your surname or organisation name as a reference.

Credit Card:
For credit card payments, please complete the attached credit card payment form to be returned via post, fax or email. Download Form Here

Thank you for submitting your request to become a network member, we will process your application as soon as possible.

* This Field is required Required field | This Field IS visible on profile Field visible on your profile | This Field IS NOT visible on profile Field not visible on profile | Information for: ? : Field description: Move mouse over icon Information: Point mouse to icon
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