Please note that fields marked with an asterisk (*) are required in order to successfully register your application.
* Reduced, Suspended or Revoked Clinical Privileges
Have your clinical privileges and / or appointment at any hospital or day procedure centre ever been reduced, suspended or revoked or have you had conditions attached to that appointment for any reason? If so, please specify:
* Medical Registration Conditions
Are there any conditions attached to your medical registration? If so, please provide details:
* Professional Indemnity Insurance Issues
Has your professional indemnity insurer / fund ever applied conditions or refused to renew your cover or membership? If so, please provide details:
*Please attach your current resume
(include three (3) recent work referees - name, address, and fax/email/tel):
I, the abovementioned, by clicking the 'Submit my Application' button, certify that the information contained herein is full and accurate.
Suite 1, 53 Cleary Street
Hamilton, NSW 2303
02 4924 8000
+612 4924 8000