Application for Appointment as Intern-HMO 2017

Please note: if you need to correct any error in your application, please initial
the correction.
Please attach to this form
Current Curriculum Vitae including certified copies of all original qualifications

Copies of relevant Visa documents

SECTION 1: INFORMATION, INSTRUCTIONS
APPLICATION RETURN
Please return completed applications to:
Sandi Collins
JMO Support Officer
Albury Wodonga Health
PO Box 326
Albury NSW 2640
Email: sandi.collins@awh.org.au

Liz Caunt
Manager, Medical Workforce Unit
Albury Wodonga Health
PO Box 326
Albury NSW 2640
Email: liz.caunt@awh.org.au

Enquiries can be directed to:

Liz Caunt

SECTION 2: PERSONAL DETAILS

FAMILY NAME:

DATE OF BIRTH:

Female
FIRST NAME:

OTHER NAMES:

AUSTRALIAN CITIZEN:
PROFESSIONAL ADDRESS:

Male

PLACE OF BIRTH:
YES

NO

IF NO, VISA CLASS:

CLASS NUMBER:
PERMANENT RESIDENT OF AUSTRALIA:
YES

CITY

STATE

POSTCODE

RESIDENTIAL ADDRESS:

MOBILE TELEPHONE:
FAX:
HOME TELPHONE:
EMAIL ADDRESS:

CITY:

STATE:

POSTCODE:
APPOINTMENT TYPE:
HMO

j/medicalworkforceunit/recruitment/2017/awh intern-hmo application form

NO

SECTION 3: REFEREES
Every applicant must list at least two professional referees.
NAME:

TELEPHONE:
YEARS KNOWN:

ADDRESS:

PROFESSIONAL RELATIONSHIP (eg supervisor,

colleague)

NAME:

TELEPHONE:
YEARS KNOWN:

ADDRESS:

PROFESSIONAL RELATIONSHIP (eg supervisor,

colleague)

NAME:

TELEPHONE:
YEARS KNOWN:

ADDRESS:

RELATIONSHIP (eg supervisor, colleague)

SECTION 4: AGREEMENTS/UNDERTAKINGS
I understand that in assessing my application for appointment the health service may
make additional enquiries as to my suitability for the position.
I authorise the health service to conduct a police record check in relation to
my history.
I authorise the health service to obtain information relevant to my
application from my medical indemnity insurance organisation.
I authorise the health service to seek information as to my past experience,
performance and current fitness.
If appointed, I agree to familiarise myself with relevant hospital bylaws,
policies and procedures and to abide by them.
If appointed, I agree to abide by confidentiality and privacy obligations and
understand that breaches may result in the cessation of my appointment.
I agree to notify the Director of Medical Services of any event/situation
which may impact on my ability to exercise my scope of clinical practice,
whether it be due to medical registration matters, or otherwise.
I agree to promptly notify the Director of Medical Services of any adverse
clinical incident I am involved in or become aware of.

j/medicalworkforceunit/recruitment/2017/awh intern-hmo application form

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

SECTION 5:

Additional information

Albury Wodonga Health wish to employ HMOs who

See the value in spending time in a regional health service
Appreciate the benefits of a closer relationship with registrars and consultants in making the
transition from Intern to HMO with the increased responsibility.
Wish to develop skills in interaction with patients and their families. We see greater
opportunities for this in a community based health service.

Please tell us about:

Your personal achievements (medical and non-medical) over the last 5 years
Why you have chosen to spend time in a regional hospital, in particular AWH.
Your thoughts on your long term medical career accepting that as new graduates you still
need to explore options and may not be able to nominate a particular pathway at this stage.

j/medicalworkforceunit/recruitment/2017/awh intern-hmo application form