• Please write clearly in black ink using capital letters, in English.
  • The declaration at the back of this form must be signed by the applicant.
  • All late and incomplete applications submitted will NOT be accepted.
  • You may insert additional rows to sections in this document or attach appendices as required.

APPLICANT’S DETAILS

Full Name: ………………………………………………………………………..Trainee ID:......

Street: ……………………………………………………………………………….Suburb: ……………………………………………………………………………..

State:…………………………………………………………………………………Postcode: ………………………………………………………………………….

Mobile: ………………………………………………………………………………...... Work Phone: ……………………………………….……………………………

Email:...... …………………………………………………………………………………………………………………………. Gender:  Female  Male

  1. Do you hold the FRANZCOG? Yes ☐ No ☐
  2. Current year of training: Year 4 ☐ Year 5 ☐ Year 6 ☐
  3. I confirm that I have satisfactorily completed a minimum of 138 weeks of FRANZCOG Core Training and am eligible to apply as per regulation D1.2.

(Mandatory requirement)

  1. Number of satisfactorily completed weeks of Advanced Training:………………………….
  2. Date commenced FRANZCOG training: ……………………………………………………………………
  3. Date passed the FRANZCOG examinations: written: ………………… oral: …………………….
  4. Date completed FRANZCOG training (if applicable): …………………………………………………

EDUCATIONAL HISTORY
Degree / Qualification / University / Date Obtained
EMPLOYMENT HISTORY

Please list all clinical employment history.

Employment Date / Employer / Position
PROFESSIONAL DEVELOPMENT AND COMMITMENT TO THE CREI SUBSPECIALTY

Please list all relevant professional development activities and describe your previous interest and/or experience in the CREI Subspecialty (please attach an appendix if necessary)

Activity Completed / Completion Date
TEACHING AND LEADERSHIP EXPERIENCE

Briefly describe any previous teaching experience and leadership positions held.

Audience e.g. Undergraduate/Postgraduate / Brief Description of Teaching Role / Year
Leadership Role / Brief Description of Responsibilities / Year
RESEARCH, PUBLICATIONS AND PRESENTATIONS

Briefly describe research you have been involved in.

Title of Project / Role of Applicant / Names of co-researchers / Date Completed

List publications you have authored/co-authored.

Authors / Title of Publication / Journal Reference

List presentations you have made at conferences or scientific meetings.

Title of Presentation / Names of co-presenters / Conference/
Scientific Meeting / Date Presented
REFERENCES

Applicants are required to provide the names and contact details of three referees

The three referees must be:

  • A senior colleague (FRANZCOG) with whom you have worked within the last two years. Applicants who are currently in the FRANZCOG training program must nominate their current Training Supervisor as the senior colleague.
  • Two other colleagues with whom the applicant has worked within the last two years.

Please ensure you contact your referees prior to applying.

Email addresses and telephone numbers of all referees must be provided.

Applicants will be contacted to confirm receipt of all references, or if there are any issues with these.

References are provided in strict confidence by referees, therefore applicants must not contact referees about any aspect of the reference provided.

EMAIL ADDRESSES AND TELEPHONE NUMBERS OF ALL REFEREES MUST BE PROVIDED

REFEREE ONE

Is this person your current Training Supervisor? YES ☐ NO ☐

Name:
Title: / Post-nominals
Work Address:
Telephone: / Mobile: / Work:
Email:

REFEREE TWO

Is this person your current Training Supervisor? YES ☐ NO ☐

Name:
Title: / Post-nominals
Work Address:
Telephone: / Mobile: / Work:
Email:

REFEREE THREE

Is this person your current Training Supervisor? YES ☐ NO ☐

Name:
Title: / Post-nominals
Work Address:
Telephone: / Mobile: / Work:
Email:
CURRICULUM VITAE

A current CV is to be attached to the application.

DECLARATION

I certify that I have no restrictions, conditions or any other limitations on my medical registration(s) and that the information contained in this application is true and accurate.

I have read and understood RANZCOG Regulation Section D1.2 pertaining to eligibility to apply to the College for assessment to enter the Subspecialty Training Program, and I am eligible to apply.

I understand the Subspecialties National Selection Process and the substance of all discussions must remain confidential at all times.

Name: ……………………………………………………………………………………………. Date: ………………………………………………

Signature: ………………………………………………………………………………………

PRIVACY POLICY

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) adheres to the principles of privacy legislation in both Australia and New Zealand to ensure that personal information about individuals which is held in the College records in both hard copy and electronic form is treated in accordance with the standards set by the relevant legislation.

For more information please refer to the RANZCOG Privacy Policy

INTERVIEWS

National Selection applicants selected to proceed to interview are required to attend in person in Melbourne.

Reproductive Endocrinology and Infertility – Chair, Dr Clare Boothroyd - Friday 18 May 2018

APPLICATION FEE

A non-refundable application fee of $AUD305.00 applies to the Subspecialties National Selection Process.

Applicants will be required to pay this fee online at the time of application.

NOTES
  • A covering letter must be submitted with the completed application form and should be addressed to the Chair, CREI Subspecialty Committee.
  • Additional material supporting the application demonstrating the applicant’s interest in the subspecialty for which they are applying may also be added as an appendix to a completed application form.
  • Full and complete applications, including completed references, must be received by the College by the closing time and date.

Reproductive Endocrinology and Infertility
National Selection Process Applications
must be received no later than
5:00pm SATURDAY 31 MARCH 2018 (AEDT)
Applications are to be sent to:
Chair,CREI Subspecialty Committee
Email:
Post: RANZCOG, 254-260 Albert St, East Melbourne, VIC 3002
ENQUIRIES

For further information about commencing subspecialty training or the National Selection Process, please contact:

Kate Gilliam, SeniorCoordinator, Subspecialties Training Program- or +61 9412 2959

Subspecialty National Selection Application
Form for CREI Applicants 2018 (2019 Entry)Page 1 of 5NS 7/4 - 02