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Candidate Centre Registration

Candidate Details Candidate Profile  

* indicates required fields.
 
 
Contact Details
Title *
First Name *
Last Name *
Phone (H)
Phone (W)
Mobile
Email *
 
Postal Address
Address 1
Address 2
City / Town
State *
Post Code
Country
 
Resume
 
Attach Personal Resume
Size Limit: 2 MB
Formats Allowed: .doc, .docx, .pdf, .odt, .html, .htm, .txt, .rtf
 
LinkedIn Profile
Please click on the Attach button, to attach your LinkedIn profile. Once attached you can click on the View link to review.
Attach LinkedIn Profile  View
Additional Documentation
AHPRA Registration

Size Limit: 500 KB per document
Formats Allowed: .doc, .docx, .pdf, .odt, .html, .htm, .txt, .rtf
Certificate of Insurance

Size Limit: 500 KB per document
Formats Allowed: .doc, .docx, .pdf, .odt, .html, .htm, .txt, .rtf
Qualification

Size Limit: 500 KB per document
Formats Allowed: .doc, .docx, .pdf, .odt, .html, .htm, .txt, .rtf
De Identified Medical report 1

Size Limit: 500 KB per document
Formats Allowed: .doc, .docx, .pdf, .odt, .html, .htm, .txt, .rtf
De Identified Medical report 2

Size Limit: 500 KB per document
Formats Allowed: .doc, .docx, .pdf, .odt, .html, .htm, .txt, .rtf
Peak Body Membership /Fellowship

Size Limit: 500 KB per document
Formats Allowed: .doc, .docx, .pdf, .odt, .html, .htm, .txt, .rtf
Proof of CPD

Size Limit: 500 KB per document
Formats Allowed: .doc, .docx, .pdf, .odt, .html, .htm, .txt, .rtf
Additional Documentation 1

Size Limit: 500 KB per document
Formats Allowed: .doc, .docx, .pdf, .odt, .html, .htm, .txt, .rtf
Additional Documentation 2

Size Limit: 500 KB per document
Formats Allowed: .doc, .docx, .pdf, .odt, .html, .htm, .txt, .rtf
 
Access Password (for future online application/s)
Username
(Your email address.)
Password *
At least 7 letters and/or numbers (case sensitive)
Confirm Password *
 
  

* indicates required fields.
 
Are you currently engaged by Worksafe Victoria for IME services?* Yes     No
Preferred Location  *
Current Selection:
Select multiple fields by holding CTRL key while clicking.
Skills
Select multiple fields by holding CTRL key while clicking.
If other(s) specify
Language / Level*
To add a language, select the language and level of fluency from the drop down, by a scale of 1-5 (1 being basic, 5 being highly advanced) and click on the Add button.
  
If other(s) specify
Work/Residency Status *
Category / Sub-Category *



To add the values required, please click on the Add button.
  
How do you want to be sent referrals? 
   
Practices and availability
Main Practice:
Address Line 1
Address Line 2
Provider Number
Phone Number
Email Address
Availability
MON TUE WED THU FRI SAT SUN
Frequency

Practice 2:
Address Line 1
Address Line 2
Provider Number
Phone Number
Email Address
Availability
MON TUE WED THU FRI SAT SUN
Frequency

Practice 3:
Address Line 1
Address Line 2
Provider Number
Phone Number
Email Address
Availability
MON TUE WED THU FRI SAT SUN
Frequency

Practice 4:
Address Line 1
Address Line 2
Provider Number
Phone Number
Email Address
Availability
MON TUE WED THU FRI SAT SUN
Frequency
Consent and Declaration
I have read and understood the WorkSafe Victoria IME Privacy Statement and I consent to the collection and use of personal information by for the purposes outlined in the statement, and I authorise WorkSafe to disclose this information to the types of organisations listed in the statement for any of those purposes. I declare that all information contained in this application is correct and complete and that I have read and understood the Independent Medical Examiner Declaration, and that if selected and approved, I will comply with all of the terms of the Independent Medical Examiner Declaration.   
Yes, I agree with the Privacy Statement of WorkSafe Victoria IME
No, I don't agree.