• REGISTRATION DETAILS

    Please use these details to register and if log in (after account has been approved)
  • Please complete all 5 Sections of this Application Form. Once completed, you will be directed to enter the Geographic distribution of operating beds for your company.
  • DETAILS OF OWNER (IF APPLICANT IS NOT THE OWNER)*


  • Form of Proxy:

    Please download PDF, sign and return.
  • Drop files here or
  • DETAILS OF APPLICANT

  • Represented by (Full Name)
  • PROVIDER NAME (COMPLETE ALL RELEVANT FIELDS)

  • REFERRAL BY EXISITNG PSHA MEMBER

    *Complete this section only if you wish to nominate a director to the PSHA Board.
  • DECLARATION

  • This field is for validation purposes and should be left unchanged.