Curriculum Vitae

Personal Details

Family name (Surname):
Given names:
Date of Birth
Gender: / Male / Female
Country of Birth:
Current homeaddress: / Address line 1
Address line 2
Surburb State Postcode
Phone: / (M) Mobile / (H)Home phone
Current workaddress: / Address line 1
Address line 2
Surburb State Postcode
Phone: / (W) Work phone / (Fax) Facsimile if applicable
email address: / Enter eMail address
Additional email address: / Enter eMail address
I am a permanent resident of Australia / I am a temporary resident of Australia
I am in Australia on Student/Visitor Visa / I am in Australia on OtherVisa

Qualifications

Primary Medical Qualification (MBBS or equivalent)

Qualification title:
Year qualified:
Year awarded (If different to year qualified):
Country of training:
Medical school:
Controlling university:
Was a period of internship included in qualification? YES / NO
If yes, include dates (month/year):from: Enter Month Yearto: Enter Month Year

Additional Qualifications:

Qualification title:
Year qualified:
Year awarded:
Country of training:
Institution awarding qualification:
Qualification title:
Year qualified:
Year awarded:
Country of training:
Institution awarding qualification:
Qualification title:
Year qualified:
Year awarded:
Country of training:
Institution awarding qualification:
Qualification title:
Year qualified:
Year awarded:
Country of training:
Institution awarding qualification:
Qualification title:
Year qualified:
Year awarded:
Country of training:
Institution awarding qualification:

Memberships of Professional Organisations:

Please include memberships of all relevant organisations:

Date From/To: / Organisation:
from: to:
from: to:
from: to:
from: to:
from: to:

TRAINING:

Internship:

Date started:
Date ended:
Institute/Facility/Practice:
Address:
Rotations:

Certificates and Courses:

Please list all relevant courses attended and certificates gained:

Date: / Course/Certificate:

Clinical/Procedural Skills:

Competent: / Observed:

WORK HISTORY:

Detailed Employment History:

Please list all employment details in chronological order starting with your current or most recent employer to the oldest employer being at the end of the list. Also, list any gaps appearing in your employment history e.g. include dates started/ended and an explanation for the gap in employment:

Date started:
Date ended:
Position(s):
Institute/Facility/Practice:
Address:
Duties:
Date started:
Date ended:
Position(s):
Institute/Facility/Practice:
Address:
Duties:
Date started:
Date ended:
Position(s):
Institute/Facility/Practice:
Address:
Duties:
Date started:
Date ended:
Position(s):
Institute/Facility/Practice:
Address:
Duties:
Date started:
Date ended:
Position(s):
Institute/Facility/Practice:
Address:
Duties:
Date started:
Date ended:
Position(s):
Institute/Facility/Practice:
Address:
Duties:
Date started:
Date ended:
Position(s):
Institute/Facility/Practice:
Address:
Duties:
Date started:
Date ended:
Position(s):
Institute/Facility/Practice:
Address:
Duties:
Date started:
Date ended:
Position(s):
Institute/Facility/Practice:
Address:
Duties:
Date started:
Date ended:
Position(s):
Institute/Facility/Practice:
Address:
Duties:
Date started:
Date ended:
Position(s):
Institute/Facility/Practice:
Address:
Duties:
Date started:
Date ended:
Position(s):
Institute/Facility/Practice:
Address:
Duties:

Gaps in Work/Practice History:

Provide an explanation of six months or more since obtaining your professional qualifications where you have not practiced and reasons
(e.g. undertaking study, travel, and/or family commitment).

Date started:
Date ended:
Reason:
Date started:
Date ended:
Reason:
Date started:
Date ended:
Reason:
Date started:
Date ended:
Reason:
Date started:
Date ended:
Reason:

Current AND All Previous Medical Licensing Authorities:

Type of registration: / Date (from/to): / Registering authority: / List restrictions,
conditions or
undertakings:
From: to:
From: to:
From: to:
From: to:
From: to:

If you have current AHPRA Medical Registration, either limited or provisional, please attach a copy of your current registration certificate.

Other Activities:

Please include details of any other important activities: (you should include details of other relevant professional activities or achievements (e.g. officer bearer in a professional organisation, course instructor or examiner appointment).

Continuing Professional Development activities:

Please include details of any CPD (Continuing Professional Development)activities you have undertaken in the previous three years.

Please attach a copy of your CPD (Continuing Professional Development) points list accumulated achieved/obtained to date over the past 5 years old only.

Referees:

Professional referees only, no relatives, referees need to be those that have worked with you within the last five years;

Referee 1 / Referee 2 / Referee 3
Name:
Position:
Address:
Phone number:
Email address:
* Date:

*Specify month year of most recent contact with referee:

Verification Statement:

I Enter full name:consent to Health Workforce Assessment, Victoria (HWAV) contacting interested parties including the Medical Board of Australia (MBA) and the Australian Health Practitioner Regulation Agency (AHPRA), referees, contacts named in this Curriculum Vitae (CV) and my PESCI Application form and other relevant parties.

I verify that the information contained within this Curriculum Vitae (CV) is true and correct as at:Enter date:
Signature: ______
Print name: Enter full name:
Date of signing:Enter date:

HWAV | 07 2016 | 16 | 002.1Page 1 of 8July 2016