Application
Form
Accident
& Medical Care Course 2010
Closing
date for applications:
31 January
2010
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Please email this form, or print and send to AMPA at 202 Ponsonby Rd, Ponsonby, Auckland, or fax to (09) 3765783.
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Applicant |
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| Name: |
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| Date of Birth: |
Gender: |
| Address - street: |
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| Address - suburb: |
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| Address - city: |
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| Home phone: | Work phone: |
| Home fax: | Work fax: |
| Mobile: | |
| Email: | |
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Current Employment |
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| Name of principal A&M/ED
workplace: | |
| Is facility open until 8pm seven
days a week? | |
| Does facility have x-ray on-site? | |
| Address of facility - street: | |
| Address of facility - suburb: | |
| Address of facility - city: | |
| Position held: | |
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Do you want to join AMPA?
Note: AMPA has two main functions.
It represents the interests of its members, and it provides
training in A&M Practice. You may elect to join the
training programme, join AMPA, either or both. There is no
additional cost for trainees to join AMPA. |
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Class
of membership sought (associate [free] / full / none):
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| Do you want to join the
Training Programme?
Note: If you want to become a Fellow of AMPA, you must
join the training programme. New Zealand A&M or ED hours
will only be recognised if you are a member of the Training
Programme at the time you work those hours.
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Do you wish to join the A&M training
programme?
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Have
you had two
years of supervised postgraduate general medical training,
including one pre-registration intern year and one year
including posts in general medicine and/or surgery in full
time supervised positions?
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| Clinical experience |
| General practice
experience: |
Where: |
| When: |
| Approx hours: |
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| Overseas A&M
experience: |
Where: |
| When: |
| Approx. hours: |
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| Overseas ED
experience: |
Where: |
| When: |
| Approx. hours: |
| Other experience / other
information |
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Postgraduate qualifications:
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CTA Funding
I meet CTA criteria 2-6
and apply for a CTA funded training position
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MCNZ number |
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MCNZ scope of practice |
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Ethnicity |
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European nfd, New Zealand European/Pakeha, Other European,
New Zealand Maori, Pacific Island nfd, Samoan, Cook Island Maori, Tongan, Niuean,
Tokelauan, Fijian, Other Pacific Island Groups, Asian nfd, Southeast Asian, Chinese,
Indian, Other Asian, Middle Eastern, Latin American/Hispanic, African or cultural group of
African origin, Other Ethnicity, nfd - 'not further defined' |
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I intend to work in the following facilities
in the next twelve months: |
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