PodNZ Member Application Form 2025
First Name
Last Name
Gender
Select an option
Male
Female
Other
Date of Birth
Registration Number
Personal Email
Work Email
Personal Phone Number
Work Phone Number
Work Address
Employer or Business name
Business website
Do you wish to be located via our "Find a Podiatrist" search function?
Select an option
Select an option
Yes please
No thanks
Insurance Declaration
200
In the last 10 years have any claims for breach of professional duty been made against you, your business, your business predecessors or any current or former parters/principals/directors or other employees?
Select an option
Yes
No
Are you aware of any circumstances that may result in a claim against you, your business or any of your business partners/principals/directors or employees?
Select an option
Yes
No
Have you or any partner/principal/director or employee ever been fined or penalised, or been the subject of an enquiry or disciplinary proceedings for professional misconduct?
Select an option
Yes
No
Has an insurer ever cancelled your insurance policy or has any insurer declined to renew your insurance policy?
Select an option
Yes
No
By completing this application, I agree to abide by the terms and conditions of membership and standards of behaviour must be adhered to as outlined in the Members Manual and on the PodiatryNZ website.
Your Signature
*
Clear
Date
Which membership type best fits for you? See https://www.podnz.org/membership-types-1 for full descriptions.
Select an option
Full-time
Part-time
Graduate Year One
Graduate Year Two
Non-practising
Academic
Administration
Submit application