PERSONAL DETAILSName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Preferred Name First Last Gender*MaleFemaleDate of Birth* Date Format: DD slash MM slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Home PhoneWork PhoneMobileAre you a NZ Citizen?*YesNoAre you a NZ Citizen?*YesNoIf not, do you have permanent resident status?YesNoWhich ethnic group(s) do you belong to?New Zealand EuropeanAsianPacificMāoriOther EuropeanQUALIFICATIONSDegreeUniversity/College/ CountryDate Completed MEDICAL REGISTRATIONType of Registration:*ProvisionalGeneralVocationalDate of Registration in NZ* Date Format: DD slash MM slash YYYY MCNZ No:*Expiry Date of current practicing certificate:* Date Format: DD slash MM slash YYYY POST GRADUATE EXPERIENCEPlease detail all post graduate experience and in particular all details pertaining to relevant experience in Musculoskeletal MedicineYearsPositionOversight/SupervisorFacility RECOGNITION OF PRIOR LEARNING (RPL) I have read the NZAMM’s policy with respect to Prior Learning I wish to apply for recognition of prior learning I do not intend on applying for recognition of prior learning RESEARCHPlease list any peer reviewed journal articles/chapters in medical texts/popular press articles of a medical nature which you have had published TEACHING EXPERIENCEPlease list your involvement in teaching doctors, students or the public MEMBERSHIP OF RELEVANT SOCIETIESPlease note your membership of relevant medical societies or associations MUSCULOSKELETAL MEDICINEPlease write a brief paragraph on why you would like to be a Musculoskeletal Medicine Fellow and what abilities you have that would make you a good practitioner of this discipline, and how you could contribute furthering Musculoskeletal MedicineREFEREESNameOrganisation & PositionEmailPhone DISCLOSUREThe Association requires all applicants for acceptance into the Training Programme to declare any health issues that may impact on their ability to practice competently and safely. In addition, the NZAMM asks to be informed about any unresolved complaints, disciplinary procedures or previous criminal convictions. This applies from the time of this application, during Training and on an ongoing basis assuming the applicant is successful in achieving Certificate of Attainment in Musculoskeletal Medicine(CAMM) Please document any such relevant information on a separate document. All declarations received are kept confidential to senior programme staff.Acknowledgement* Yes I understand and accept this requirement Yes, I have attached my declaration on a separate sheet No, I do not have anything to declare. SUPPORTING DOCUMENTATION AND DECLARATIONPlease enclose the following documents Select All A full curriculum vitae Copy of current Annual Practising Certificate A recent Photograph Certified copies of relevant Degrees & Diplomas Copy of current Medical Indemnity Proof of Identity – certified copy of passport / driver’s license Upload all the above selected documents Drop files here or Accepted file types: jpg, png, pdf, jpeg, doc. Make sure all documents are named correctly with your name as a prefixDECLARATIONI, hereby confirm that the above information is correct and true to the best of my knowledge. I consent to the Faculty of Musculoskeletal Medicine contacting any relevant persons to verify the above information.