Hospital Health Workforce Certificate Application Form

Applicant details

This application form is for hospital-based positions only. Those seeking a Health Workforce Certificate for positions other than hospital-based positions should use the Standard Form available at http://www.visasforgps.com.au/for-practices

Hospital-based Position Details

1. Practitioner One

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Practitioner One Main Hospital Address

Practitioner One Secondary Hospital Address (if applicable)

2. Practitioner Two (if applicable)

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Practitioner Two Main Hospital Location

Practitioner Two Secondary Hospital Address (if applicable)

3. Practitioner Three (if applicable)

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Practitioner Three Main Hospital Address

Practitioner Three Secondary Hospital Address (if applicable)

4. Practitioner Four (if applicable)

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Practitioner Four Main Hospital Address

Practitioner Four Secondary Hospital Address (if applicable)

Agreement

I understand that giving false or misleading information is a serious offence, and I declare that details provided in this form are correct. *
I understand that information I provide will be shared with other bodies responsible for the Visas for GPs initiative, including the Australian Government Department of Health, and Department of Home Affairs, and that all personal information relating to this application is protected by law under the Privacy Act 1988. *

Optional