TGA use only

This form, when completed, will be classified as 'For official use only'.
For guidance on how your information will be treated by the TGA see: Treatment of information provided to the TGA at <

Medical officer application coversheet

The information provided by you in this online application form is collected to assist the Therapeutic Goods Administration (TGA) to determine your suitability for selection to an advertised vacancy. Information collected from applicants and other information collected during the assessment process is managed under the Privacy Act 1988.

Please attach this form to the front of every application.

  1. Job details

Medical Officer
I am interested in being considered for Medical Officer vacancies in the following locations: / Canberra Sydney Melbourne
I am interested in working: / Full time Part time Casual
I first saw the vacancy advertised in the following media:
  1. Personal details

Title: / Surname: / Male Female
Given Name(s):
Postal address:
State: / Post code:
Contact phone number during working hours:
Email address (optional):
Are you an Australian citizen? / Yes No
If not, when will you be eligible to apply for Australian citizenship?
Are you a permanent resident? / Yes No
If not, please provide visa details (incl. dates):
Have you received a voluntary redundancy benefit from an APS Agency or equivalent in the last 12 months? / Yes No
If so, on what date?
  1. Tertiary qualifications

Name of degree/qualification / Year obtained
  1. Current APS employment details (if applicable)

Current APS Agency:
AGS No:
Classification:
Employment Status:
  1. Diversity Information (for statistical purposes only)

Age: 16-2425-3435-4445-5455+
Do you have a disability? / Yes No
Do you identify as an Aboriginal or Torres Strait Islander? / Yes No
Are you from a non-English speaking background? / Yes No
If you require any special equipment or assistance to attend an interview or complete a work sample test, please provide details:
  1. Specialist experience

Please detail any experience as a medical specialist, including the total number of years experience.
Medical/Professional Specialty / Total Years Experience
Any other relevant professional experience:
  1. Medical registration

Australian National Medical Registration Number:
  1. Declaration

I declare that the information I have provided in this form and attached to this application is true and correct. I understand and agree that giving false or misleading information is an offence and may disqualify me from employment, or result in dismissal, if I am offered employment, or employed by the TGA.
Signature:
If submitting electronically, please type your name / Date:

Medical officer application coversheet (July 2014)Page 1 of 3

For official use only