Training Form | NZCMM

PERSONAL DETAILS

Name*

Prefix First Last

Preferred Name

First Last

Gender*

Male
Female
Other Gender

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Mobile

Are you a NZ Citizen?*

Yes
No

If not, do you have permanent resident status?

Yes
No

QUALIFICATIONS

Degree	University/College/ Country	Date Completed

MEDICAL REGISTRATION

Type of Registration:*

Provisional
General
Vocational

Date of Registration in NZ*

MCNZ No:*

Expiry Date of current practicing certificate:*

POST GRADUATE EXPERIENCE

Please detail all post graduate experience and in particular all details pertaining to relevant experience in Musculoskeletal Medicine

Years	Position	Oversight/Supervisor	Facility

RECOGNITION OF PRIOR LEARNING (RPL)

I have read the NZCMM’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

RESEARCH

Please list any peer reviewed journal articles/chapters in medical texts/popular press articles of a medical nature which you have had published

TEACHING EXPERIENCE

Please list your involvement in teaching doctors, students or the public

MEMBERSHIP OF RELEVANT SOCIETIES

Please note your membership of relevant medical societies or associations

MUSCULOSKELETAL MEDICINE

Please 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 Medicine

REFEREES

Name	Organisation & Position	Email	Phone

DISCLOSURE

The College 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 NZCMM 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 DECLARATION

Please 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, Max. file size: 2 MB.

Make sure all documents are named correctly with your name as a prefix

DECLARATION

I, 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.

I agree that I have the read the Privacy Statement*

Yes

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