ALMS Candidate Application - Deputising

Full Name*

Gender Please Select Female Male

Marital Status Please Select Single Married

Address

Home Phone

Work Phone

Email*

Fax

Date of Birth

Year of Graduation

Institution / University

Provider Number

VR / NON VR

Available

Time Preference

Area Preference

Special Qualifications

Medical (Insurance) Provider

Country Placements? Please Select Yes No

Do you have a Car? Please Select Yes No

Driver's License? Please Select Yes No

Requested Dates From

Work Location Preference? Please Select Melbourne Perth

Surname

Given Names

Date of Birth

Relationship to You

Citizenship of Passport

Passport Number

Passport Issuing Authority

Passport Expiry Date

Please provide a CV in the following format

1. Surname

2. Given name(s)

3. Date Of birth

4. Gender

5. Residential Address

6. Telephone (Please specify: country code, area code and telephone number)

7. Facsimile: (Please specify: country code, area code and telephone number)

8. Email address

9. Place of birth

10. Nationality

11. Citizenship on passport

12. First language

13. Other languages and degree of proficiency (written and spoken)

14. Qualifications section (as outlined below):

15. Are you fully registered as a medical practitioner in your country of residence?

16. When did you obtain full registration in your country of residence?

17. Have you sat the usa qualifying examination? (If yes, you will need to provide evidence of successful completion of that examination).

18. Employment history

a. General practice or family medicine employment history (in assessing your application, the medical practitioners board will place particular importance on your private general practice or family medicine experience. accordingly, please ensure that the information you provide in this regard is comprehensive. for example, you must provide all relevant dates, ie, specify the full period for each post; provide full details about the practice, ie, name and address; details of your independent role or position in the practice as well as examples of common presentation).

b. Other employment history (please provide all relevant date, ie, specify the full period of each post as well as the name and address of each institution or practice).

c. any other relevant information

19. Referees:

Please provide the names and full contact details of three referees. Please note also that your application cannot be submitted for consideration by the medical practitioners board without at least one written reference.

20. Attachments:

Please fax a copy of at least one written reference and a copy of your current medical registration certificate to ALMS - facsimile: +61 3 9347-8017.

Upload resume