GP Registration Form

APPLICANT DETAILS:

Title*

Surname*

Given Name/s:*

Date of Bith:*

Home Address:

Suburb:

State:

P/Code:

AHPRA Registration Number:

Type of Registration

Contact Details

Mobile:*

Home:*

Email:*

Are you an Australian Citizen / Permanent Resident?*

Do you have a working visa?*

Visa Type:

Issued Date:

Visa Number:

Expiry Date:

CLINICAL REFEREE DETAILS:

(Pls. note: Two referees are required. At least one referee should have been working with you in your past or existing role)

1. Name of Referee:*

Name of Organisation & Position Held:*

Contact No:*

Email*

Last worked with you:*

2. Name of Referee:*

Name of Organisation & Position Held:*

Contact No:*

Email*

Last worked with you:*

FINANCIAL DETAILS:

ABN:

Banking Details

BSB:

Account No:

Account Name:

Bank / Branch:

MEDICARE INFORMATION:

Prescriber No:*

Existing Provider No:*

Are you affected by 19AB?

When does your moratorium expire?

Are you affected by 19AA?

Which 3GA program are you currently enrolled on?

EMERGENCY CONTACT:

Surname:*

Given Name/s:*

Relationship to you:*

CERTIFICATION:

I hereby certify that the above information is correct and complete to the best of my knowledge and belief. I understand that, if I am contracted, I will be liable to dismissal if any of the statements in my application are found to be deliberately misleading.

*

Please upload copies of the documents below:

Passport*

Drop files here or

Drivers License*

Drop files here or

Medical Indemnity Insurance*

Drop files here or

CV (in word format)*

Drop files here or

Working with Children Check

Drop files here or

Visa (if not an Australian Citizen)

Drop files here or

Security Code*

Note: Security Code is case sensitive.

GP Registration Form

APPLICANT DETAILS:

Contact Details

CLINICAL REFEREE DETAILS:

FINANCIAL DETAILS:

Banking Details

MEDICARE INFORMATION:

EMERGENCY CONTACT:

CERTIFICATION:

Please upload copies of the documents below:

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