Fields marked with an asterisk * are required.

Part 1: Personal Data

Name:
 
First Name*                Last Name*
Date of Birth:
1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 January February March April May June July August September October November December 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Gender:
Not selected Male Female
Street Address*:

State:

Country:
Australia New Zealand United Kingdom
Phone*:

Fax:

Mobile:

Email*:


Best contact times:
 Business Hours
 After Hours
 Weekdays
 Weekends

Part 2: Skills, Experience & Job Preferences

Position type:
 Locum (Full-time)
 Locum (Part-time)
 Registrar (all)
 Registrar (accredited only)
 CMO
 GP

Registered In:
 NSW
 QLD
 ACT
 SA
 WA
 NT
 TAS
 VIC
 NZ
 UK

Minimum acceptable remuneration:
(based on gross per annum)


Acceptable Departments:


Permission for AHSR to contact
your referees for more info

Citizenships:

Experience:

Qualifications/Degree:

Preferred Localities:


Required ASAP:

Earliest Start:
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2010 2011 2012 2013
Sessions Available:
 Monday morning
 Tuesday morning
 Wednesday morning
 Thursday morning
 Friday morning
 Saturday morning
 Sunday morning
 Monday afternoon
 Tuesday afternoon
 Wednesday afternoon
 Thursday afternoon
 Friday afternoon
 Saturday afternoon
 Sunday afternoon

Duration (days):
(minimum)   (maximum)
Notice Required (days):


Travel Assistance Required

Accomodation Required

Taken IELTS/TOEFL/Cambridge

Contacted employers/agencies:
no   yes
Further if information if "yes"


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