Agency Membership Application

We manually review all Agency Membership applications and request that you complete this form in full so that we can create your account. This application form will take approximately 5 minutes to complete.

Your Details

First Name ^* (required)

Last Name ^* (required)

Email Address ^* (required)

Function/Role ^* (required)

Telephone Number ^* (required)

Choose your Membership

Select Agency Membership Level ^* (required)

Term of Membership ^* (required)

2 Years (recommended)

1 Year

Your Agency / Company Details

Agency / Company Name ^* (required)

Agency / Company Name (Native)

Sector ^* (required)

Type of Business ^* (required)

Expertise ^* (required)

Public Email Address

Public Telephone Number

Website Address

Address Line 1 ^* (required)

Address Line 2

Address Line 3

Town/City ^* (required)

ZIP/Post Code ^* (required)

State / Province / Territory

Country ^* (required)

Please upload your Logo

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Agency / Company Description

Key Contacts for your Account

To help us manage your account please can you provide the details of the following Key Contacts within your organisation. You can always change these later.

Head of Service/CEO - Name and Function will be shown on your public Connect Directory profile. Official correspondence from ICPA will be addressed to this individual.

Are you the Head of Service/CEO?

If this is you, please click here and go to the next Point of Contact (POC)

Head of Service: Title / Salutation

Head of Service: First Name

Head of Service: Last Name

Head of Service: Function/Role

Head of Service: Email Address

Membership Point of Contact - This is the administrator for your ICPA account and our primary point of contact. This individual will be responsible for maintaining your organisation details, public profile and applying complimentary memberships. All correspondence from ICPA will be copied to this person.

Are you the Membership Point of Contact?

If this is you, please click here and go to the next Point of Contact (POC)

Membership POC: Title / Salutation

Membership POC: First Name

Membership POC: Last Name

Membership POC: Function/Role

Membership POC: Email Address

Finance Point of Contact - This individual will receive notifications from ICPA concerning billing and invoice information.

Are you the Finance Point of Contact?

If this is you, please click here and go to the next Point of Contact (POC)

Finance POC: Title / Salutation

Finance POC: First Name

Finance POC: Last Name

Finance POC: Function/Role

Finance POC: Email Address

Communications Point of Contact - This should be the individual in your agency who is responsible for managing media relations, communications, publicity, etc. We will contact this person with regards to social media campaigns, contributions to newsletters, etc.

Are you the Communications Point of Contact?

If this is you, please click here and move to the next section

Communications POC: Title/Salutation

Communications POC: First Name

Communications POC: Last Name

Communications POC: Function/Role

Communications POC: Email Address

How did you hear about ICPA? ^* (required)

I agree that ICPA will use the information provided to process this application and, following approval, to create a membership account and directory profile ^* (required)

Please check this box before submitting your application