Register as a Doctor
Australian Citizen Unconditional GP
Personal/Contact Details
Last/Family name:
First name:
Preferred name:
Date of Birth (not compulsory):
Gender:
female
male
Telephone (home):
Telephone (work):
Telephone (mobile):
Fax:
Current Residential Address:
Email address:
Please indicate your preferred method of contact:
Tel (home)
Tel (work)
Tel (mobile)
Fax
Email
Qualification Details
Where did you undertake your primary qualification?
Primary qualification type:
Year of qualification:
Are you currently Vocationally Registered?
yes
no
no, but in process of obtaining it
Are you currently working?
yes
no
Work History
Where you have worked in the last 5 years?
Name of General Practice
Suburb & State
Date from
Date to
Referees (you must have worked with these two people in the last 1-5 years):
Name
Relationship (eg colleague, principal, etc)
Contact numbers
Current state you are registered in:
[Select State]
New South Wales
Queensland
ACT
Victoria
SA
NT
Tasmania
Registration Number:
Registered until:
Restrictions/Conditions (if applicable):
Medical Indemnity Details
Indemnity Provider:
Number:
Current until:
Work Preferences
State you would like to work in:
[Select State]
New South Wales
Queensland
ACT
Victoria
SA
NT
Tasmania
City / country area you would like to work in:
Type of work you are seeking:
Locum
Sessional
Daily
Weekly
Full-Time
Part-Time
Are you looking for work as a:
Contractor
Employee
Remuneration Expectations:
Hourly Rate
OR
Percentage
Start Date:
Finish Date:
Please indicate any requirements
(such as accommodation, travel, family etc):
Referral
How did your hear about us?
[Please Select]
advertisement
from a colleague
AGPR Rewards member
web search
other
If applicable, name of AGPR Rewards member:
