Application Form – Special Training Fellowship in Psychiatry

Personal Details

Title / Given Names / Family Name

Contact Details

Work Mailing Address
Work Mailing Address (cont) / Suburb / State / Postcode
Home Mailing Address
Home Mailing Address (cont) / Suburb / State / Postcode
Work Phone / Work Email
Mobile / Home Email

Preferred Contact

Preferred Phone / Preferred Email / Preferred Address
☐ / Home / ☐ / Work / ☐ / Home / ☐ / Work

Citizenship / Residency Status

☐ / Australian Citizen / Permanent Resident / ☐ / Other: / Details

Training and Experience

RANZCP

Training Commencement / MCQ – completion or next sitting
Date / Date
Written Exams Completion / Attainment of FRANZCP
Date / Date

Proposed Fellowship

Title of Special Training Proposal

Fellowship Requested

/ ☐ / Full Time / ☐ / Part Time / If part time, please indicate: / %
If you are offered a part time fellowship instead of a full time fellowship would this be acceptable? / ☐ / Yes / ☐ / No

Research Component

/ Does the proposed fellowship include a research component? / ☐ / Yes / ☐ / No
If yes and you are successful in obtaining a fellowship ethics requirements will be discussed before commencing your fellowship.

Principal Supervisor

Title / Given Names / Family Name
Phone / Email

Advanced Training Program

/ Please indicate which AT program you are/will be enrolled in

Other Information

How did you hear about this Fellowship? / Other:

Submission

Applications should be returned to Neridah Callaghan at HETI by email:
Please mark documents included:
☐ / Report of proposed training experience (max 1000 words) / ☐ / Letter of endorsement from the Director of Training where the proposed training will occur
☐ / CV / ☐ / Letter of support from the Director of Advanced Training
☐ / Evidence of completion of stage 2 training / ☐ / Letter of support from the Supervisor of the proposed project

DECLARATION

I have read and understand the HETI Information Sheet about the Special Training Fellowships. / ☐ / I Agree / ☐ / I do not agree

An application receipt confirmation will be sent via email to your preferred email address

HETI Admin Use Only

Admin Signature / Date Received / Entered in Database / Date Applicant Notified by Email