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Registration Form
Experience
First Name
*
*
Last Name
*
Email
*
*
Phone Number
*
Location (State)
*
Have you previously been known by another name?
*
Aborginal or Torres Strait Islander
Aborginal or Torres Strait Islander
No
Aborginal or Torres Strait Islander
Yes
Date of Birth
*
Preferred method of contact
What is your most current role? (select one)
If you selected Allied Health. Please list your specialty
*
Which areas of nursing have you previously worked in?
What qualifications do you hold?
*
How many years of nursing experience do you have?
*
*
Which hospital program/s are you experienced with?
Do you have a HAD ID?
Do you have a HAD ID?
No
Do you have a HAD ID?
Yes
If you selected "yes" to the Had ID enter ID here.
*
Which facilities have you worked in?
Have you worked in either a remote or rural location?
Have you worked in either a remote or rural location?
No
Have you worked in either a remote or rural location?
Yes
If "yes", please list a couple of the locations.
*
Are you interested in working in a remote or rural
Are you interested in working in a remote or rural
No
Are you interested in working in a remote or rural
Yes
What is your preferred placement duration?
2 weeks
4 weeks
6 weeks
8 weeks
12 weeks
Other
What type of role are you looking for?
*
Which of the following current mandatory certificates do you have?
Do you have any of the following certifications (current)?
Which of the following skillsets / experiences do you have?
Do you have a Police Check issued in the last 12 months?
Do you have a Police Check issued in the last 12 months?
No
Do you have a Police Check issued in the last 12 months?
Yes
Which State/s do you have a current Working With Children Check?
Do you have a current NDIS Clearance?
Do you have a current NDIS Clearance?
No
Do you have a current NDIS Clearance?
Yes
What are your working rights in Australia?
Australian Citizenship
Permanent Resident
Visa Holder
New Zealand Citizen
None of the above
Are you up to date with your State Health Department Mandatory Vaccinations?
Are you up to date with your State Health Department Mandatory Vaccinations?
No
Are you up to date with your State Health Department Mandatory Vaccinations?
Yes
If you selected 'other' for any of the questions, please describe why here.
*
I consent to my Compliance Documents being shared with Hospitals / Local Health Networks / Area Health Networks? (If no, we may not be able to progress your application).
I consent to my Compliance Documents being shared with Hospitals / Local Health Networks / Area Health Networks? (If no, we may not be able to progress your application).
No
I consent to my Compliance Documents being shared with Hospitals / Local Health Networks / Area Health Networks? (If no, we may not be able to progress your application).
Yes
References
Referees must have been a direct clinical supervisor or manager and have worked with the candidate within the past 12 months.
1) Referee First Name
*
1) Referee Last Name
*
1st Reference's email
*
*
*
2) Referee First Name
*
2) Referee Last Name
*
2nd Reference's Email
*
*
3) Referee First Name
*
3) Referee Last Name
*
3rd Reference's Email
*
*
CV/ Resume
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