Australian and New Zealand College of Anaesthetists
2018 INTERNATIONAL SCHOLARSHIP
APPLICATION FORM
PART A
Personal Information
1. Name in full:
(Family name) (First name) (Middle name)
Preferred name:
(If different from first name)
Previous family name:
(If different from current family name)
2. Address:
Home:
Phone: Fax:
Email:
Work:
Phone: Fax:
Email:
Tick which of the above addresses you would like correspondence sent to: Home Work
3. Date of birth:
4. Nationality:
5. Marital status:
(a) Name of spouse (if applicable):
(b) Name/s of children and ages (if applicable):
PART B
Qualifications and experience
1. Basic academic qualifications (with dates and names of educational institution awarding qualification. Please attach certified copies.):
2. Post graduate degrees or diplomas gained (with dates and names of educational institution awarding qualification. Please attach certified copies.):
3. Results of IELTS or equivalent English language test (A valid IELTS or equivalent test score mandatory for medical registration and scholarship in both Australia and New Zealand):
4. Details of any specific anaesthetic, intensive care or pain medicine training and/or experience since graduation (hospitals; dates and duration of attachment to each unit; capacity in which the attachment was undertaken; names of supervisors):
5. Current appointment(s):
6. Duties (Description of clinical and other duties):
7. Teaching experience:
8. Other achievements, experience, interest and activities (Include professional qualifications):
9. Other information: (Include any other information which may be helpful to the selection committee)
PART C
Proposed Program of Activities
1. What is your proposed program or course of study?
2. What objectives do you have in promoting anaesthesia and/or pain medicine in your home country?
PART D
Referees AND ENDORSEMENT
1. Name of supervisor or hospital/institution (where you wish to undertake your scholarship) who you are known to in Australia or New Zealand and who has agreed to support your application (required)
Name:
Position:
Hospital:
2. Name and address of senior anaesthetist or director from your current hospital, university, institution or local anaesthesia society who will support your application (required):
Name:
Position:
Address:
3. Name and address of authorised government officer or equivalent who will endorse your application for this scholarship:
Name:
Position:
Address:
4. Names and addresses of additional referees:
Name:
Position:
Address:
Phone: Fax :
Email:
Name:
Position:
Address:
Phone: Fax :
Email:
PART E
Declaration of applicant
I solemnly declare that the statements made in this application are true and accurate.
SIGNATURE: DATE:
Notes:
A. Personal information
First name: If your first name is hyphenated or two words, e.g., Wu Xiao Ping, Anne-Marie Jones, enter this in the first name box.
Preferred name: Only complete if the name you prefer to be called by is not your first name. For example, you may go by your middle name, or use an ‘English’ name. This will help ensure that we get your name correct on correspondence, name tags and other communications.
Previous family name: If your family name has changed since birth by marriage or deed poll, you must include a copy of your marriage certificate, change of name notice or your medical registration indicating a change of name.
Photograph: You must supply one passport quality photograph.
· Eyes should be open and clearly visible.
· Glasses may be worn as long as the eyes are clearly visible. Sunglasses are unacceptable.
· The photo should be taken against a plain, white or light-coloured background.
· Both black & white and colour photographs are acceptable, though colour is preferred.
· Secure the photograph to the form (this will be scanned.)
Nationality the scholarship is open to residents of developing countries as recognised by the Australian Minister for Foreign Affairs http://www.ausaid.gov.au/ngos/devel_list.cfm .
IELTS: Valid results must be provided along with your application for the scholarship. As tests are only valid for two years, please confirm validity of previous test results prior to submission. Strict English language registration requirements are set by the Australian Medical Council and Medical Council of New Zealand. Information about these requirements can be found at:
Australian Medical Council https://www.ahpra.gov.au/documents/default.aspx?record=WD15%2f16888&dbid=AP&chksum=Qt6fclXbe4YXYTcrrq%2fUjg%3d%3d
Medical Council of New Zealand
https://www.mcnz.org.nz/assets/Policies/English-language-policy-2014-final.pdf
B. QUALIFICATIONS AND EXPERIENCE
The scholarship is only open to anaesthetists or pain medicine specialists who have graduated from their respective country’s anaesthesia or pain medicine training program. As each country has a different system for training anaesthetists, please ensure you provide information detailing all of your relevant qualifications. A full CV (submitted on Australian Medical Council Pro Forma) is also required.
Australian Medical Council Pro Forma
www.amc.org.au/joomla-files/images/forms/curriculum-vitae-template.doc
C. PROPOSED PROGRAM OF ACTIVITIES
Please provide details as to what skills and knowledge you would like to improve whilst undertaking the scholarship.
It is important to demonstrate how undertaking the scholarship will be of benefit to your community upon return to your home country. Please explain how you will be able to utilise the skills you learn either through teaching or clinical practice to benefit those at home.
D. REFEREES AND ENDORSEMENT
Please provide the contact details of a senior anaesthetist or your department director who is able to write in support of your application and your proposed program for undertaking the scholarship.
Please provide the contact details of the authorised government officer or equivalent who will endorse your application and confirm that you are able to leave your position during the scholarship period to undertake the additional training.
Please provide the contact details of a supervisor or suitable person from a hospital / institution who you are known to in Australia or New Zealand who is able to write in support of your application and your proposed program for undertaking the scholarship.
Checklist
Completed ANZCA registration form
One passport-size photograph
Photocopy of passport
Full curriculum vitae (submitted on the AMA CV pro forma)
Note: Please include certified copies of your basic academic qualifications and post graduate degrees/diplomas.
IELTS results or equivalent meeting the required Australian or New Zealand standards
A letter of support from the senior anaesthetist or director from your hospital, university or institution (See part C, question 1). It is the candidate’s responsibility to obtain such a letter, which may be sent separately or directly by the person concerned.
A letter of support from a hospital/institution and/or supervisor who you are known to in Australia or New Zealand indicating a willingness to offer a suitable position for the duration of the scholarship (12 months).
A letter of endorsement from the authorised government officer (See part D, question 3).
It is the candidate’s responsibility to obtain this letter, which may be sent separately or directly by the person concerned.
This application must reach the address below no later than MONDAY APRIL 3, 2017 (emailed applications are acceptable). No late applications will be considered.
Mr John Ilott
Chief Executive Officer
Australian and New Zealand College of Anaesthetists
630 St Kilda Road
Melbourne 3004
Australia
Fax: +61 3 9510 6786
Email:
If you have any queries or require further information, please contact Kate Davis, Policy Officer at the College on ph.: +61 3 9093 4935 or email: