INTERN 2019
Please note: if you need to correct any error in your application, please initial the correction.
Please email the completed application form and the following documentation to the email address listed below -
- Current Curriculum Vitae including certified copies of all original qualifications
- Copies of relevant Visa documents
- Cover letter
- Passport photo
- Two clinical referee reports
- One non-clinical written reference
APPLICATION RETURN
Please return completed application and additional documentation via post/email to:
Liz Caunt
Albury Wodonga Health
PO Box 326
ALBURY NSW 2640
Email:
All enquiries are to be made to Liz Caunt, Manager Medical Workforce
PERSONAL DETAILS
Family Name / Click here to enter text. /
First Name / Click here to enter text. /
Other Names / Click here to enter text. /
Address / Click here to enter text. /
City Click here to enter text. / State Click here to enter text. / Postcode Click here to enter text.
Mobile Telephone / Click here to enter text. /
Email Address / Click here to enter text. /
Date of Birth / Click here to enter text. / Female ☐ / Male ☐
Place of Birth / Click here to enter text. / Australian Citizen / Yes ☐ No ☐
Permanent Resident / Yes ☐ No ☐
If no, VISA Class / Click here to enter text. / Visa Number / Click here to enter text. /
REFEREES
Applicants must provide the names and contact details of two professional referees and one personal referee
Professional (Clinical) Referee 1
Name / Click here to enter text. /
Address / Click here to enter text. /
CityClick here to enter text. / StateClick here to enter text. / PostcodeClick here to enter text.
Mobile Telephone / Click here to enter text. / Years Known / Click here to enter text.
Professional Relationship / Click here to enter text. /
Professional (Clinical)Referee 2
Name / Click here to enter text. /
Address / Click here to enter text. /
CityClick here to enter text. / StateClick here to enter text. / PostcodeClick here to enter text.
Mobile Telephone / Click here to enter text. / Years Known / Click here to enter text. /
Professional Relationship / Click here to enter text. /
Personal (Non Clinical) Referee
Name / Click here to enter text. /
Address / Click here to enter text. /
CityClick here to enter text. / StateClick here to enter text. / PostcodeClick here to enter text.
Mobile Telephone / Click here to enter text. / Years Known / Click here to enter text. /
Relationship / Click here to enter text. /
Please include Clinical Referee reports and Personal Reference as attachments to this application form.
Note: Clinical Referee reports are available via PMCV computer matching website -
AGREEMENTS / UNDERTAKINGS
I understand that in assessing my application for appointment the health service may make additional enquiries as to my suitability for the position.
I authorise the health service to conduct a police record check in relation to my history. / Yes ☐ / No ☐
I authorise the health service to obtain information relevant to my application from my medical indemnity insurance organisation. / Yes ☐ / No ☐
I authorise the health service to seek information as to my past experience, performance and current fitness. / Yes ☐ / No ☐
If appointed, I agree to familiarise myself with relevant hospital bylaws, policies and procedures and to abide by them. / Yes ☐ / No ☐
If appointed, I agree to abide by confidentiality and privacy obligations and understand that breaches may result in the cessation of my appointment. / Yes ☐ / No ☐
I agree to notify the Director of Medical Services of any event/situation which may impact on my ability to exercise my scope of clinical practice, whether it be due to medical registration matters, or otherwise. / Yes ☐ / No ☐
I agree to promptly notify the Director of Medical Services of any adverse clinical incident I am involved in or become aware of. / Yes ☐ / No ☐
OTHER MATTERS
Have you ever been convicted or found guilty or any criminal offence, including a drug or alcohol-related offence? / Yes ☐ / No ☐
Are you the subject of current or pending criminal charges? / Yes ☐ / No ☐
Is there any condition that we need to be aware of that might impact you to perform your duties. / Yes ☐ / No ☐
If you answered yes to either of the above, please provide full details in a document marked “Confidential for HMO Manager” attached to this application and indicate here that additional information is provided separately in this manner. Click here to enter text.
ADDITIONAL INFORMATION
Albury Wodonga Health wish to employ Interns who -
- See the value in spending time in a regional health service.
- Appreciate the benefits of a closer relationship with registrars and consultants.
- Wish to develop skills in interaction with patients and their families. We see greater opportunities for this in a community based health service.
Briefly, tell us about -
Your personal achievements over the last 5 years.
Click here to enter text.
Why you have chosen to spend time in a regional hospital, in particular AWH.
Click here to enter text.
Your thoughts on your long term medical career, accepting that as new graduates you still need to explore options and may not be able to nominate a particular pathway at this stage.
Click here to enter text.
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Intern Application Form 2018