Cosmetic Medical Training Program Application

First Name(s)

Surname

Date of Birth

Email Contact

Contact Number

Principal Practice Details

Street Address

Suburb

State

Post Code

Postal Address Details

Postal Address

Suburb

State

Post Code

Other Locations Details

Practice Address

Suburb

State

Post Code

University of Graduation

Year

Qualifications/Post-graduate Degrees/Diplomas

Registration No.

Please list any restrictions or conditions imposed

Memberships

Australian Medical Association CPCA AMSA International Society of Cosmetic Laser Surgeons American Society for Lasers in Medicine Other

Accompanying Documentation

Indemnity Insurance Company

Indemnity Insurance Policy No

Please attach copy of Medical Indemnity Insurance Evidence of cover, Certificate of Currency (required)

Medical Registration/Annual Practicing Certificate (required)

Other Training - (Summary Only - full details in CV)

Curriculum Vitae (required)i

This should contain a comprehensive outline of medical and surgical training.

Copies of all Degrees/Diplomas are required in support of this application

$330.00 (Inc GST) For non-refundable administration costs.