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

Registration No.

Please list any restrictions or conditions imposed

Memberships

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

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 Vitae (required)i

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 (required)

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.