APPLICATION FORM FOR
ASSESSMENT OF
AUSTRALIAN GENERAL PRACTICE EXPERIENCE
If you fall under the Practice Eligible route and intend to undergo the College assessment process, you will need to complete this assessment form to have your general practice experience assessed by the College.Please refer to the policy for an outline of the eligibility criteria of this assessment:
ALL APPLICANTS WILL NEED TO PROVIDE THE FOLLOWING DOCUMENTATION
CONFIRM THAT YOU CAN PROVIDE WHAT HAS BEEN REQUESTED BY MARKING EACH BOX WITH A TICK
Written confirmation (on practice letterhead) dated and signed by the principal* from the practice(s) or relevant
hospital(s) or clinic(s) indicating:
  • the specific dates you were/are employed
  • the exact nature of the work you are/were required to cover, including the duties you performed. (This information will be crucial in determining if your work is considered as general practice experience)
  • whether you worked full time* or part time (Please provide total hours worked each week)
  • and the duration of your weekly sessions (for example: Monday-Friday 9am-12:30pm & 1:30pm-5pm) A session does not include your meal break.
*Please note the principal is a general practitioner who is the owner of the practice, if the principal is unavailable or if the practice has no principals, we will accept a letter from a Senior Medical Director, CEO, Director, or Practice Manager. Also note If you are the sole principal of the practice, you will need to provide the above information in the form of a Statutory declaration, for more information please visit: you will also need to provide two letters of support from other health professionals confirming that you have referred patients to them from your practice (for example, psychologists, cardiologists, dermatologists etc). However, if you are a co-principal, then you must have one of the other principals sign theletter of support as per the above instructions.
*Please note the RACGP consider full time work to be a minimum of 37 hours per week. For more information on eligibility criteria please refer to the “Assessment of Overseas General Practice Experience and Australian General Practice Experience” policy:
Acopy of your current medical registration (an expiry date must be shown).
A certified copy of your primary medical degree. (If your degree is printed in another language, we require both a translated and untranslated copy of the original)
If your primary medical degree shows a different name we also require a certified copy of your change of name certificate or marriage certificate.
A letter of approval from the RACGP Censor-in-Chief indicating previous assessment of time
(If applicable).
A copy of your current curriculum vitae.

The censor may request further information upon review of your application.

You may contact the Contact Team – Education Services on 1800 626 901 if you have questions or problems related to these documents.

For guidelines on certification of documents, please refer to our witnessing and certification policy:

Fellowship Services Branch

APPLICATION FORM FOR
ASSESSMENT OF
AUSTRALIAN GENERAL PRACTICE EXPERIENCE
When filling out this application please print clearly. Type written applications preferred.
For what purpose do you require an assessment of your Australian general practice experience? (Tick relevant box)
ENROLMENT IN THE NEXT:
College Examination / Practice Based Assessment / Entry into the Specialist Pathway / Full Membership / Other
PERSONAL DETAILS
First name(s)
Middle name(s)
Surname
Date of birth / RACGP No#
PRACTICE ADDRESS
Practice name
Street address
Suburb/town
State / Post Code
HOME ADDRESS
Street address
Suburb/town
State / Post Code
POSTAL ADDRESS
Street address
Suburb/town
State / Post Code
PHONE, FAX & EMAIL
Home phone (include area code)
Practice phone (include area code)
Fax (include area code)
Mobile phone (include area code)
Email Address
ACADEMIC BACKGROUND
Primary Qualification / Date awarded / (Office use only)
Qualification
University
Country
Other Medical Qualification / Date awarded / (Office use only)
Qualification
University
Country
Non-Medical Qualification / Date awarded / (Office use only)
Qualification
University
Country
Australian Medical Registration / Registration No. / (Office use only)
Status
Start date
Expiry date
Registration body
HOSPITAL EXPERIENCE including REGISTRATION YEAR
(Attach additional page if required)
Note:Hospital experience is not generally considered to be equivalent to general practice experience. However, if any of your hospital work involved general practice related duties and you wish to have this assessed as general practice experience, please make reference to this in the next section (general practice experience). Please ensure you refer to the checklist towards the start of this form regarding information you should provide.
Hospital
(Name, town/city, country) / (Office use only)
Discipline
Date / From / To
Duration / Years / Months
Hospital
(Name, town/city, country) / (Office use only)
Discipline
Date / From / To
Duration / Years / Months
AUSTRALIAN GENERAL PRACTICE EXPERIENCE
(Attach additional page if required)
Please note: Minimum acceptable part-time experience is 10.5 hours (three sessions per week) in the one practice for a minimum of one month.
The duration of your weekly sessions (for example: Monday-Friday 9am-12:30pm & 1:30pm-5pm) A session does not include your meal break.
Practice name / (Office use only)
Practice address
Date / From / To
Full time hours per week / Part time hours per week / Years
Months
Average single session duration / Total sessions per week
Practice name / (Office use only)
Practice address
Date / From / To
Full time hours per week / Part time hours per week / Years
Months
Average single session duration / Total sessions per week
Practice name / (Office use only)
Practice address
Date / From / To
Full time hours per week / Part time hours per week / Years
Months
Average single session duration / Total sessions per week
Practice name / (Office use only)
Practice address
Date / From / To
Full time hours per week / Part time hours per week / Years
Months
Average single session duration / Total sessions per week
Practice name / (Office use only)
Practice address
Date / From / To
Full time hours per week / Part time hours per week / Years
Months
Average single session duration / Total sessions per week
INDEMNITY
I acknowledge that the RoyalAustralianCollege of General Practitioners (RACGP) will rely upon the accuracy and truth of the statements and information that I provide in this application in order to assess the time I have spent in Australian general practice. I hereby indemnify RACGP and will keep RACGP indemnified for any loss, cost or expense incurred by RACGP as a result of any claim, action, demand or proceeding brought by any person in respect of loss or damage arising from any false, misleading or inaccurate statement or information provided by me in this application.
I also undertake to provide all details of any current or pending investigations, review, inquiry or sanction by the Australian Health Practitioner Regulation Agency, Professional Services Review Director, Medicare Australia or any similar body in relation to my professional practice or behaviour in Australia.
Applicant Name
Signature / Date
Witness* Name
Title
Witness* Signature / Date

*Please refer to our “Witnessing and Certification of Documentation Policy” to determine who is eligible to witness your indemnity form at:


PAYMENT DETAILS FOR
APPLICATION FOR ASSESSMENT OF
AUSTRALIAN GENERAL PRACTICE EXPERIENCE
FEE PAYABLE / MEMBER / $165.00
NON-MEMBER / $275.00
TAX INVOICE
The RoyalAustralianCollege of General Practitioners
100 Wellington Parade East Melbourne VIC 3002 Australia
ACN 000 223 807 ABN 34 000 223 807
Please retain a copy of this document as it will become your tax invoice/receipt upon payment
First Name
Surname / RACGP No.
(if applicable)
Preferred daytime contact number:
DATE / RACGP MEMBER /  / YES /  / NO
 / CHEQUE (make payable to the RACGP) /  / Amex /  / Visa /  / MasterCard
CARD NUMBER /    
CARDHOLDER
NAME(please print clearly) / EXPIRY DATE  / 
CARDHOLDER SIGNATURE / TOTAL AMOUNT $AUD

Please print clearly and keep a copy of this form for your records. For more information telephone 1800 626 901 or email . All fees quoted are GST free. This form will become your tax invoice upon payment. ABN 34 000 223 807.

OFFICE USE ONLY
Batch No. / Order No. / Invoice No.

Application form for assessment of Australian general practice experience September 2011 Page 1 of 7