Application for Appointment as Intern-HMO

Please note: if you need to correct any error in your application, please initial the correction.
Please attach to this form –
  • Current Curriculum Vitae including certified copies of all original qualifications
  • Copies of relevant Visa documents

SECTION 1: INFORMATION, INSTRUCTIONS
APPLICATION RETURN

Please return completed applications to:Liz Caunt

Manager, Medical Workforce Unit

AlburyWodonga Health

PO Box 326

Albury NSW 2640

Email:

Fax: (02) 6051 7543

Enquiries can be directed to:Liz Caunt

SECTION 2: PERSONAL DETAILS
FAMILY NAME: / DATE OF BIRTH:
 Female Male
FIRST NAME:OTHER NAMES: / PLACE OF BIRTH:
AUSTRALIAN CITIZEN:YES NO
PROFESSIONAL ADDRESS: / IF NO, VISA CLASS:
CLASS NUMBER:
PERMANENT RESIDENT OF AUSTRALIA:
YES NO
CITY / STATE / POSTCODE / MOBILE TELEPHONE:
RESIDENTIAL ADDRESS: / FAX:
HOME TELPHONE:
EMAIL ADDRESS:
CITY: / STATE: / POSTCODE:
APPOINTMENT TYPE:HMO
SECTION 3: REFEREES
Everyapplicantmust list at leasttwoprofessional referees.
NAME: / TELEPHONE:
YEARS KNOWN:
ADDRESS: / PROFESSIONAL RELATIONSHIP (eg supervisor, colleague)
NAME: / TELEPHONE:
YEARS KNOWN:
ADDRESS: / PROFESSIONAL RELATIONSHIP (eg supervisor, colleague)
NAME: / TELEPHONE:
YEARS KNOWN:
ADDRESS: / RELATIONSHIP (eg supervisor, colleague)
SECTION 4: 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
SECTION 5: Additional information

AlburyWodonga Health wish to employ HMOs who

  • See the value in spending time in a regional health service
  • Appreciate the benefits of a closer relationship with registrars and consultants in making the transition from Intern to HMO with the increased responsibility.
  • Wish to develop skills in interaction with patients and their families. We see greater opportunities for this in a community based health service.

Please tell us about:

  • Your personal achievements (medical and non-medical) over the last 5 years
  • Why you have chosen to spend time in a regional hospital, in particular AWH.
  • 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.

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