ACRRM Registrar Pathway Enrolment and Membership Application 2011-12

Australian College of
Rural and Remote Medicine

Call Us:: 1800 223 226

Home
Membership
Pay an invoice
Find a Fellow
Feedback
Contact
Site Login

About
Programs
Curriculum
Courses & Events
Resources
News
Advocacy & Policy

Follow us on...

@ACRRM

Join

Join ACRRM

Enjoy member benefits, develop your career…

Collaborate

Opportunities to partner with ACRRM …

Online Learning

RRMEO, clinical guidelines, online groups …

Work

Jobs at ACRRM, member’s practices, hospitals, etc..

Find us on Facebook

Australian College of Rural and Remote Medicine (ACRRM) on Facebook

@ACRRM on Twitter

Home

Last updated: 19 May 2011

My Pathway

I have been accepted into the: *

Remote Vocational Training Scheme (RVTS) pathway

Australian General Practice Training (AGPT) pathway

The date I was accepted: *

My Regional Training Provider is: *

ACRRM enrolment: *

I wish to enrol in the Australian College of Rural and Remote Medicine's Vocational Training program and to apply for Registrar Membership to train for Fellowship of ACRRM. I understand I must maintain current financial membership of ACRRM throughout my training.

My Identity

Title: *

First name: *

Other name/s:

Family name: *

Date of birth: *

Gender: *

Female

Male

I am:

Aboriginal

Torres Strait Islander

Private Contact Details

Street address: *

Town / Suburb: *

State: *

Postcode: *

Country: *

Phone:

Mobile phone: *

Fax:

Email: *

Business Contact Details

Business name: *

Street address: *

Town / Suburb: *

State: *

Postcode: *

Country: *

Phone:

Mobile phone: *

Fax:

Email: *

For correspondence, I prefer the College uses my: *

Medical Registration

National medical registration number: *

Primary Medical Qualifications

Date: *

Qualification: *

Institution: *

Country: *

Other Medical Qualifications

Please state date, qualification, institution and country:

College Activities

I would like information about:

The ACRRM Registrar Committee

Mentoring a medical student

Participating in my area/s of interest (eg anaesthetics, obstetrics).

My area/s of special interest are:

Declaration: *

I declare that the information on this form is, to the best of my knowledge, complete and correct. I acknowledge that my membership to ACRRM is bound by the policies and procedures of the College. As a member I shall uphold the Objects of ACRRM and abide by the Regulations and the Code of Professional Ethics and Conduct which requires me to observe the highest standards of clinical, professional and ethical behaviour in all of my activities.

Privacy and use of information: *

I understand ACRRM will collect, store and share the information I provide on this form for the purposes of providing membership services, and for reporting on my education and training programs. ACRRM shares information with medical boards, training providers, government health departments and authorities (such as GPET). ACRRM may be obliged to share information with other organisations if it receives a valid legal demand.

I am employed by Queensland Health and authorise ACRRM to send this department information relevant to my training.

Payment

Fee: *

$235.00 (Fees are based on membership for a full financial year (1 July to 30 June). Pro-rata fees apply eg if you join in December, 6 months fees are payable).

How to pay: *

Direct Deposit: Account name: ACRRM; BSB: 034 003; Account number: 264808; Reference: Enter your full name in the reference field

Cheque or Money Order: Please make payable to: Australian College of Rural and Remote Medicine and post to ACRRM, GPO Box 2507, Brisbane QLD 4001

Credit Card: Please call the College on Freecall 1800 223 226. Have your credit card details ready

CAPTCHA

This question is for testing whether you are a human visitor and to prevent automated spam submissions. All alphabetic characters are lowercase.

What code is in the image?: *

Enter the characters shown in the image.

Top of Page
Home
Find a Fellow
Feedback
Site Map
Disclaimer
Privacy
Contact Us

This site complies with the HONcode standard for trustworthy health information:
verify here.

Follow us on...

Join ACRRM

Collaborate

Online Learning

Work

Find us on Facebook

Follow us on Twitter

ACRRM Registrar Pathway Enrolment and Membership Application 2011-12