Fellowship Application form

EVIDENCE OF GENERAL PRACTICE EXPERIENCEHave you successfully completed an Australian GP Vocational Training Program? YesOffice UseOnlyPlease attach notification of your successful completion from your Regional Training Provider?You do not need to supply any other evidence of General Practice ExperienceCompletion Date: ………/………/………NOMINATION OF REFEREESYou are required to nominate the names of two (2) referees, one of whom must be a current financial Fellowor Member of the RACGP. A nominated referee must not be a relative of the applicant.Referee 1. Surname: ……………………………………………………............................RACGP No.: …………………………………Practice name and address: …………………………………………………………………………………………………………………………Suburb: …………………………………………………………………. State: ……………………… Postcode: …..……………………..Phone: (……)……………………………………………………………Fax: (……)……………………………………………………………Signed: ……………………………………………………….…………Referee 2. Surname: ……………………………………………………............................RACGP No.: …………………………………Practice name and address: …………………………………………………………………………………………………………………………Suburb: …………………………………………………………………. State: ……………………… Postcode: …..……………………..Phone: (……)……………………………………………………………Fax: (……)……………………………………………………………Signed: ……………………………………………………….…………DECLARATIONI hereby agree, if so required to appear for an interview at the State/Territory Office by the College Censor, and• To uphold and promote to the best of my ability, the aims and objectives of the College;• To undertake the College requirements for Quality Assurance and Continuing Professional Development (QA&CPD);I reaffirm my declaration to uphold and abide by the College’s Constitution and its regulations and policies, including our EthicsPolicy.I declare that the information I have provided on this application form and its attachments is correct.SIGNATURE: ……….. ………………………………………………….DATE: …………/…………/…………Copies of the College’s Constitution and out Ethics Policy is available on the RACGP Website at www.racgp.org.auPLEASE ENSURE THAT YOU HAVE COMPLETED ALL SECTIONS OF THIS FORM AND HAVEINCLUDED ANY REQUIRED ATTACHMENTS BEFORE SUBMITTING TO YOUR STATE/TERRITORYFACULTY OFFICE, INCOMPLETE APPLICATIONS WILL BE RETURNED TO YOU FOR COMPLETION.PRIVACY POLICY: The RACGP has a Privacy policy that reflects the recent changes in Federal and State privacy legislation. You may obtain a full copy of the College’s policy from ourwebsite: www.racgp.org.auAssessment Department: Revised 23 April 2010 Page 2 of 3

STATE FACULTYOFFICE USE ONLYRACGP No: …………………………… State Faculty: ………………..…………………… Date Received: ………………………………Financial Yes No (NB: Applications can only be processed if Membership is current.)Current Medical Registration confirmed Yes No Date: …………/…………/…………Insert expiry date of registrationReferred to State Censor Yes No Date: …………/…………/…………Recognised overseas qualifications confirmed from IMIS (if applicable) YesSignature of Faculty Officer processing applicationSignature: ………………………………………………………………… Date: …………/…………/…………RECOMMENDATIONS – STATE CENSOROFFICE USE ONLYComments: …………………………………………………………………..……………………………………………………………………..…………………………………………………………………………………………………………..………………………………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………….Application Approved Yes No DeferredCensor Name: ………………………………………… Signature: …………………………………… Date: …………/…………/…………Assessment Department: Revised 23 April 2010 Page 3 of 3