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Collects applicant contact details, identity and birth date, residential address, phone and email, and qualification background including university, qualification title, diagnostic or radiation therapy, course start/end dates, and employment history. Includes a declaration of correctness, applicant signature and date, instructions for completing the form for eligible New Zealand undergraduate qualifications or prior overseas assessment, and requirements for certified documents, English proficiency evidence, employer verification, and payment method.","| CONTACT DETAILS (Please PRINT clearly in blue or black pen) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| SURNAME |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| CERTIFICATE NAME (include evidence of change of name if applicable) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| GIVEN NAMES |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| TITLE: MR/MRS/MS/MISS/ OTHER |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| DATE OF BIRTH |  | D | D | M | M | Y |  | Y | Y | Y |  |  |  |  |  |  |  |  |  |\n| RESIDENTIAL ADDRESS |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| TOWN/SUBURB |  |  |  |  |  |  |  | STATE |  |  |  |  |  |  | POSTCODE |  |  |  |  |\n| COUNTRY |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| TEL (BH) |  |  |  |  |  |  | TEL (AH) |  |  |  |  |  |  |  |  |  |  |  |  |\n| MOBILE |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| EMAIL |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n\n\n| QUALIFICATIONS |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| NAME OF UNIVERSITY ATTENDED |  |  |  |  |  |  |  |  |  |  |  |\n| CITY |  |  |  |  |  |  | COUNTRY |  |  |  |  |\n| TITLE OF QUALIFICATION OBTAINED |  |  |  |  |  |  |  |  |  |  |  |\n| DIAGNOSTIC OR RADIATION THERAPY |  |  |  |  |  |  |  |  |  |  |  |\n| DATE COURSE COMMENCED |  | D | D | M | M | Y | Y | Y | Y |  |  |\n| DATE COURSE COMPLETED |  | D | D | M | M | Y | Y | Y | Y |  |  |\n| PLACE OF EMPLOYMENT |  |  |  |  |  |  |  |  |  |  |  |\n| EMPLOYER ADDRESS |  |  |  |  |  |  |  |  |  |  |  |\n| START DATE OF EMPLOYMENT |  | D | D | M | M | Y | Y | Y | Y |  |  |\n\n\n| FORM OF AGREEMENT |  |  |  |\n| --- | --- | --- | --- |\n| I declare that the information I have supplied in this application is complete, up-to-date and correct in every detail and that I understand that if I give false or misleading information, my application may be refused.\u003Cbr>I understand the Statement of Qualfication I am applying for is valid for a three year period after which time a further Statement of Qualfication will be issued on evidence of Continuing Professional Development (CPD) . |  |  |  |\n| APPLICANT SIGNATURE |  | DATE |  |\n\n\n| GUIDE TO COMPLETING THIS APPLICATION FORM AND SUPPORTING DOCUMENTATION |\n| --- |\n| COMPLETE THIS FORM ONLY IF YOUR QUALIFICATION IS AN UNDERGRADUATE PROGRAM FROM NEW ZEALAND\u003Cbr>OR\u003Cbr>IF YOU HAVE UNDERGONE THE OVERSEAS ASSESSMENT PROCESS PREVIOUSLY AND REQUIRE A NEW SKILLS ASSESSMENT LETTER |\n| In order for ASMIRT to process a Statement of Qualification, applicants from New Zeland are to complete and sign this application form and return it by post to:\u003Cbr>Australian Society of Medical Imaging and Radiation Therapy PO Box 16234\u003Cbr>COLLINS STREET WEST. VIC. 8007\u003Cbr>Australia.\u003Cbr>Do not fax or email these documents, as they will not be accepted. |\n| The following supporting documentation is to accompany the application:\u003Cbr>1. A certified copy* of your Radiography or Radiation Therapy qualifications from New Zealand.\u003Cbr>2. A certified copy of your current Registration/Practising Certificate/Licence from New Zealand.\u003Cbr>3. A certified copy of your marriage certificate or change name, if applicable\u003Cbr>4. Employer verification of clinical experience post-graduation (12 months’ minimum)\\#\u003Cbr>5. Payment of $338.00 Australian Dollars (payment made by Bank Draft drawn on an Australian bank or Credit Card: VISA, MasterCard, American Express) .\u003Cbr>6. Overseas currency is not accepted. Do not send cash.\u003Cbr>7. Evidence of understanding and fluency in English (i.e. IELTS/OET/PTE and~~ certified cop~~y of Passport or Birth Certificate if you are not a citizen of Australia, New Zealand, Canada, Republic of Ireland, United Kingdom or United Sta","cbCaiu7peXKX8ov3","https://ap.wps.com/l/cbCaiu7peXKX8ov3","pdf",1415479,1,"English","en",105,"# Contact details\n## Qualifications\n## Declaration and signature\n# Guide to completing the application form and supporting documentation\n## Supporting documentation requirements\n## English proficiency evidence","[{\"question\":\"Who should complete this application form?\",\"answer\":\"Complete it only if the qualification is an undergraduate program from New Zealand or if an overseas assessment process was completed previously and a new skills assessment letter is required.\"},{\"question\":\"What supporting documents must be submitted with the application?\",\"answer\":\"Submit certified copies of radiography or radiation therapy qualifications, current registration/practising certificate/licence, any marriage certificate or name-change evidence if applicable, employer verification of at least 12 months’ clinical experience, and required English proficiency evidence.\"},{\"question\":\"How is the payment handled and how long does processing take?\",\"answer\":\"Payment of 338.00 AUD is made by bank draft drawn on an Australian bank or by credit card (VISA, MasterCard, American Express). 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