Cosmetic Surgery Training Application Form

First Name(s)

Surname

Date of Birth

Email Contact

Contact Telephone Numbers

Principal Work

Principal Fax

Mobile

Home

Principal Practice Address

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

Countries of Medical Registration: Australia

New Zealand

Other

Registration No.

Please list any restrictions or conditions imposed

Any medical litigation, disciplinary action or investigation by Medical Board: No

Yes

Please provide details

Memberships: Australian Medical Association CPCA AMSA International Society of Cosmetic Laser Surgeon American Society for Lasers in Medi Othe

Please Specify

Current Hospital Accreditations for Operating Privileges

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

Referees

Accompanying Documentation

Indemnity Insurance Company

Indemnity Insurance Policy No.

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

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

Medical Registration/Annual Practicing Certificate

Logbooks of the most recent three years

Please check the Trainee Selection Policy to ensure the application is complete.

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