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A division of the Clinical Education<br />

and Training Institute (CETI)<br />

Application Form – Director of Prevocational Education and Training<br />

Question / Information to collect<br />

Response selection<br />

Part 1 - Applicant Details<br />

Applicant name<br />

Position<br />

Regional Training Provider<br />

Street address<br />

Postal address<br />

Telephone<br />

Fax<br />

Email<br />

As DPET, what area in the region will you be supporting<br />

What PGPPP practices are located in this area<br />

Are you currently registered with<br />

the Medical Board of Australia<br />

Have you ever been removed from<br />

the Register<br />

Are you under investigation or<br />

subject to disciplinary proceedings<br />

Are you a member of the following<br />

colleges:<br />

a. ACRRM<br />

b. RACGP<br />

Are you a Fellow of the following<br />

colleges:<br />

c. ACRRM<br />

d. RACGP<br />

Are you an accredited Trainer:<br />

c. ACRRM<br />

d. RACGP<br />

Yes<br />

Yes<br />

Yes<br />

Yes<br />

Yes<br />

Yes<br />

Yes<br />

Yes<br />

Yes<br />

No<br />

No<br />

No<br />

No<br />

No<br />

No<br />

No<br />

No<br />

No<br />

APPLICATION FORM DIRECTOR OF PREVOCATIONAL EDUCATION AND TRAINING page 3 of 7

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