Doctor Registration

*denotes required field

First name: *
Last name: *
Phone: *
Mobile: *
Email: *
Address:
City:
State:
Post code:
Country of residence: *
Preferred contact method: Phone Email Post
How did you hear about us: *
If you were a referred to us or recommended to use us by another doctor please advise the name of the doctor (note the reason we ask is so we can give the referring doctor a referral reward):
Preferred Speciality in Australia/NZ: * If ‘Other’, please specify:
Seniority: *
Do you hold a degree from Australia or New Zealand? Yes No *
1. Place of Primary Degree:
  
  If ‘Other’, please specify:
2. Do you have work experience in the following countries (choose one only that is most relevant):
3. Number of Months Postgraduate work experience in this country (unpaid clinical attachments not included):
4. The following are some qualifications that are either recognised or partially recognised in NZ and Australia (this is not a full list). Please indicate if you hold one of the following Postgraduate qualifications in the following countries:
  
  – Or –
  Other post graduate qualifications:
5. If no, do you have one of the following English competencies?
I am looking for work in Australia
I am looking for work in New Zealand
Preferred work (Locum or Permanent): *
Additional comments:
Attach CV:
Please check this box if we have permission to contact your referee's
Please check this box if you agree with our Terms and Conditions *

Emergency Medicine