Have you ever had any conditions, restrictions, undertakings, reprimands or notations placed Yes No on your registration either in Australia or elsewhere? Has your right to practice ever been withdrawn, suspended, terminated or reduced by an Yes No organisation, employer or professional body? Have you ever been convicted or found guilty or any criminal offence, including a drug or Yes No alcohol-related offence? Are you the subject of current or pending criminal charges? Yes No If you answered yes to any of the above, please provide full details. Or, if you prefer, provide the information in a sealed envelope marked for Manager of Medical Workforce Unit Only” appended to this application and “Confidential indicate here that additional information is provided separately in this manner. Additional information is provided separately in response to Section 7 Yes No Are you registered as a Medical Practitioner in any other country? Yes No Have you ever been registered as a Medical Practitioner in any other country? Yes No Do you have a current Working with Children Yes No If yes, please attach photocopy of current WWCC No. Expiry: document / cards for both Victoria and NSW (where applicable) WWCC No. Expiry: SECTION 6 : Medical Indemnity Insurance Information Name of current insurer Policy No. Expiry date Have there ever been, or are there currently pending, medical indemnity claims, settlements Yes No or judgements against you? Has your current or any previous medical defence organisation / insurer ever excluded or Yes No reduced any specific area of practice, or terminated or denied coverage? If the answer to either of the above two questions is Yes, please provide a detailed explanation and specify the name of the relevant medical defence organisation / insurer. SECTION 7 : Health Status Do you have a disability or health issue that:
Have you ever had any conditions, restrictions, undertakings, reprimands or notations placed on your registration either in Australia or elsewhere? Yes No Has your right to practice ever been withdrawn, suspended, terminated or reduced by an organisation, employer or professional body? Yes No Have you ever been convicted or found guilty or any criminal offence, including a drug or alcohol-related offence? Yes No Are you the subject of current or pending criminal charges? Yes No If you answered yes to any of the above, please provide full details. Or, if you prefer, provide the information in a sealed envelope marked “Confidential for Manager of Medical Workforce Unit Only” appended to this application and indicate here that additional information is provided separately in this manner. Additional information is provided separately in response to Section 7 Yes No Are you registered as a Medical Practitioner in any other country? Yes No Have you ever been registered as a Medical Practitioner in any other country? Yes No Do you have a current Working with Children Yes No If yes, please attach photocopy of current document / cards for both Victoria and NSW (where applicable) WWCC No. WWCC No. Expiry: Expiry: SECTION 6 : Medical Indemnity Insurance Information Name of current insurer Policy No. Expiry date Have there ever been, or are there currently pending, medical indemnity claims, settlements or judgements against you? Yes No Has your current or any previous medical defence organisation / insurer ever excluded or reduced any specific area of practice, or terminated or denied coverage? Yes No If the answer to either of the above two questions is Yes, please provide a detailed explanation and specify the name of the relevant medical defence organisation / insurer. SECTION 7 : Health Status Do you have a disability or health issue that: