AMC application form

15 Pages·2013·0.68 MB·English

SPECIALIST APPLICATION (A)

TO DETERMINE ELIGIBILITY TO BE ASSESSED FOR RECOGNITION AS A
SPECIALIST
If your application is assessed as incomplete, you will have to pay an incomplete application fee (A$120) and submit the
outstanding documentation within six months from the date of initial assessment. If you do not provide the required documentation,
your application will lapse and your documentation will be returned to you by using the address as recorded on your AMC records.
When you require a new assessment, you will keep your AMC candidate number. You will be required to submit a new application
by completing the relevant paper-based application including the full application fee and all required documentation. Forms
incorrectly completed will not be assessed and will be returned to candidates. Candidates will forfeit the application fee, and
another full application fee will then be required with the correctly completed application form and all required documentation as
listed in the checklist.
Lodge this form with Specialist Application (B)—Summary of Basic Medical Training and Specialist Training and Experience
and the specified supporting documents.
Please note:
 It is in your interests to ensure that the application forms and copies of documents are completed and certified correctly.
 Incorrect or incomplete applications will not be processed and a fee of A$120 will be applied.
 If Specialist Application (A), Specialist Application (B) and the specified supporting documents have not been completed and
certified correctly, referral to the relevant college will be delayed.
 You should read the information available on the AMC website (www.amc.org.au) before completing the application forms.
 You should refer to the AMC website (www.amc.org.au) for correct witnessing procedures.
STATUTORY DECLARATIONS
The AMC accepts the following as eligible to witness declarations—including Specialist Application (A) and Specialist
Application (B)—and required assessment documentation:
IN AUSTRALIA OVERSEAS
 A Justice of the Peace  Notary Public
 Chief Magistrate – Police Magistrate – Resident Magistrate –  Commissioner of Oaths (South Africa, Sudan and Canada
only)
Special Magistrate.
 A person appointed to hold, or act in, the office in a
 A person appointed under the Statutory Declarations Act
country or place outside Australia in an Australian Embassy,
1959, as amended, or under a State Act to be a
High Commission, Legation or other post as:
Commissioner for Declarations.
o Australian Consul-General, Consul or Vice-Consul.
 A Notary Public.
o Australian Trade Commissioner or Consular Agent.
 A person appointed as a Commissioner for Declarations o Australian Ambassador or High Commissioner.
o Australian Minister, Head of Mission, Commissioner,
under the Statutory Declarations Act 1911, or under that Act
Chargé d’Affaires or Counsellor.
as amended, and holding office immediately before the
o Australian Secretary or Attaché.
commencement of the Statutory Declarations Act 1959.
Note: A Justice of the Peace registered outside Australia is
NOT accepted by the AMC for witnessing documentation.
It is important that the witness state in their wording that it is a ‘certified true copy’. A sample of acceptable wording is shown below.

The name and title of the witness and the date certified must also be included in the certification. Certification should be made on
each page of the actual document. If the witness certifies the document on a separate page, it needs to be correctly notary bounded
(no staples allowed).
Application forms and documents that have not been witnessed as specified above are not legally
recognised in Australia and will not be accepted.
Updated January 2013 Page 1 of 15
TABLE 1: Areas of medical practice assessed by specialist medical colleges
Field of specialist practice Specialty code Specialist college College
code
Addiction Medicine 01 Australasian Chapter of Addiction Medicine (AChAM, RACP) 21
Adult Medicine Royal Australasian College of Physicians (RACP) 10
Adult Medicine Division
General Medicine 01
Cardiology 02
Haematologya 03
Immunology and Allergya 04
Clinical Pharmacology 05
Endocrinologya 06
Gastroenterology and Hepatology 07
Geriatric Medicine 08
Infectious Diseasesa 09
Medical Oncology 11
Neurology 12
Nuclear Medicine 13
Palliative Medicineb 14
Nephrology 15
Rheumatology 16
Clinical Genetics 18
Sleep Medicine 20
Respiratory Medicine 22
Anaesthesia 01 Australian and New Zealand College of Anaesthetists (ANZCA) 1
Dermatology 01 Australasian College of Dermatologists (ACD) 2
Emergency Medicine 01 Australasian College for Emergency Medicine (ACEM) 3
General Practice 01 Royal Australian College of General Practitioners (RACGP) 16
General Practice 01 Australian College of Rural and Remote Medicine (ACRRM) 23
Intensive Care Medicine College of Intensive Care Medicine of Australia and New Zealand (CICM) 17
Intensive Care Medicine 01
Paediatric Intensive Care Medicine 02
Medical Administration 01 Royal Australasian College of Medical Administrators (RACMA) 4
Obstetrics and Gynaecology 06 Royal Australian and New Zealand College of Obstetricians and 5
Gynaecologists (RANZCOG)
Occupational and Environmental 01 Australasian Faculty of Occupational and Environmental Medicine (AFOEM, 6
Medicine RACP)
Ophthalmology 01 Royal Australian and New Zealand College of Ophthalmologists (RANZCO) 7
Oral and Maxillofacial Surgery 01 Royal Australasian College of Dental Surgeons (RACDS) 20
Paediatrics and Child Health Royal Australasian College of Physicians (RACP), 8
Paediatrics and Child Health Division
General Paediatrics 01
Neonatology and Perinatology 02
Paediatric Subspecialties (as for Internal 03
Medicine)
Community Child Health 04
Paediatric Emergency Medicine 05
Paediatric Rehabilitation Medicine 06
Pain Medicine 01 Australian and New Zealand College of Anaesthetists, 19
Faculty of Pain Medicine (FPM, ANZCA)
Palliative Medicinec 01 Australasian Chapter of Palliative Medicine (AChPM, RACP) 18
Pathology Royal College of Pathologists of Australasia (RCPA) 9

General Pathology 01
Anatomical Pathology 02
Chemical Pathologyd 03
Haematologyd 04
Updated January 2013 Page 2 of 15
Field of specialist practice Specialty code Specialist college College
code
Immunologyd 05
Microbiologyd 06
Oral Pathology 07
Forensic Pathology 08
Genetics 09
Psychiatry 01 Royal Australian and New Zealand College of Psychiatrists (RANZCP) 11
Public Health Medicine 01 Australasian Faculty of Public Health Medicine (AFPHM, RACP) 12
Radiology Royal Australian and New Zealand College of Radiologists (RANZCR) 13
Diagnostic Radiology 01
Radiation Oncology 04
Rehabilitation Medicine 01 Australasian Faculty of Rehabilitation Medicine (AFRM, RACP) 14
Sexual Health Medicine 01 Australasian Chapter of Sexual Health Medicine (AChSHM, RACP) 22
Sport and Exercise Medicine 01 Australasian College of Sports Physicians 24
Surgery Royal Australasian College of Surgeons (RACS) 15
General Surgery 01
Cardiothoracic Surgery 02
Neurosurgery 03
Orthopaedic Surgery 04
Otolaryngology Head and Neck Surgery 05
Paediatric Surgery 06
Plastic Surgery 07
Urology 08
Vascular Surgery 09

a May also be assessed through the RCPA.
b May also be assessed through the Australasian Chapter of Palliative Medicine, RACP.
c May also be assessed through RACP.
d May also be assessed through the RACP.
Updated January 2013 Page 3 of 15
SPECIALIST APPLICATION (A)

CLIP OR GLUE
TO DETERMINE ELIGIBILITY TO BE ASSESSED FOR 1 x PASSPORT
SIZE PHOTOGRAPH
RECOGNITION AS A SPECIALIST
HERE

Please read the AMC publication Applying to the Australian Medical Council (available on the AMC DO NOT STAPLE
OR TAPE
website (www.amc.org.au) and complete this form as instructed. Incomplete or incorrect applications
will not be processed and an administration penalty fee of A$120 will be applied. Specialist
Application (A) should be lodged with the assessment fee of A$305 and specified supporting
documents. Specialist Application (A) and Specialist Application (B) will not be accepted by
email or facsimile.
IDENTITY OF APPLICANT
OFFICE USE ONLY
Family name
(Surname) FILE NUMBER

Given names

Date of birth Male Female

Day Month Year
DATE RECEIVED
STAMP
Country of birth

ADDRESS FOR CORRESPONDENCE Code: ………….…………..

Rcpt: ………………………
Address

Amount: …………………...

Prcd by: …………………...
State Postcode
Country
CONTACT DETAILS
Home phone Work phone
Mobile Facsimile
Email address
PRIMARY MEDICAL QUALIFICATION
Country of training Year qualified
Primary qualification Year awarded
Name on diploma
Medical school
Controlling university

Updated January 2013 Page 4 of 15
PRINCIPAL/HIGHEST SPECIALIST MEDICAL QUALIFICATION
(This qualification will be sent for EICS verification with your primary qualification)
Qualification obtained Year qualified
Country of training Year awarded
Institution awarding
qualification
(medical college)
Controlling university
SECONDARY/SUPPORTING SPECIALIST MEDICAL QUALIFICATION
Qualification obtained Year qualified
Country of training Year awarded
Institution awarding
qualification
(medical college)
Controlling university
ADDITIONAL SECONDARY/SUPPORTING SPECIALIST MEDICAL QUALIFICATION
Qualification obtained Year qualified
Country of training Year awarded
Institution awarding
qualification
(medical college)
Controlling university
AREA OF MEDICAL PRACTICE FOR WHICH ASSESSMENT IS SOUGHT
Field of specialisation for which assessment is sought for practice in Australia
COLLEGE CODE SPECIALTY CODE(S)
(See Table 1 in this application package for relevant college and specialty codes)
NAME CHANGE/VARIATION
Is the name shown above the same as that shown on all the attached documents? Yes No (*read below)
* If NO, you are required to attach certified documentary evidence of your change of name. If submitting a statutory declaration, ensure that all
variations are explained and state which name you wish to be known as for AMC purposes.
EVIDENCE OF ENGLISH LANGUAGE PROFICIENCY
Applicants should provide proof of their English language proficiency. If this is not provided, the AMC will require an explanation of why it has not
been provided or an indication of when it will be provided. Evidence of English language proficiency is required in accordance with the English
Language Skills Registration Standard of the Medical Board of Australia. The standard is available on the Medical Board of Australia website
(www.medicalboard.gov.au).
Updated January 2013 Page 5 of 15
EVIDENCE OF IDENTITY
All applicants applying through the Australian Medical Council (AMC) must satisfy the AMC of their identity. Applicants will need to provide proof
of personal identity by way of submission of two (2) types of identification documentation. To view these requirements, visit the AMC website
(www.amc.org.au). Please note that meeting the AMC’s requirements for identification will not necessarily satisfy the Medical Board of Australia’s
proof of identity requirements.
Tick this box if you have submitted certified evidence of identification
METHOD OF PAYMENT
I wish to have my primary and/or principal/highest specialist qualifications assessed, including EICS verification – A$305
Payment can be made by Bank cheque Money order (payable to Australian Medical Council) Credit card (see below)
PLEASE PRINT CLEARLY
Note: Recording the credit
Credit card type MasterCard Visa cardholder’s signature is taken as
consent to process the payment
(Note: MasterCard/Visa debit cards are not accepted)
Credit card number Card expiry date
Month Year
Cardholder’s signature Date
Day Month Year
Name of person to whom the AMC receipt is to be issued
PAYMENT FOR ASSESSMENT IS REQUIRED EVEN IF EICS VERIFICATION HAS ALREADY BEEN CONFIRMED
EICS VERIFICATION
Since January 2006, all applicants for the AMC examination (for non-specialist registration) and the AMC – specialist college assessment pathway
(for registration as a specialist) require primary source verification of their medical qualifications through the International Credentials Services of
the Educational Commission for Foreign Medical Graduates (ECFMG) in the United States of America.
Applicants will continue to apply to the AMC for initial assessment. Subject to the vetting of their documents by the AMC, applicants will be able to
continue with the AMC examination or the specialist assessment. The documents will be forwarded to the ECFMG for verification through the
original issuing university or institution. When confirmation of verification is received by the AMC, the candidature will be confirmed. The AMC will
not be able to issue a final AMC Certificate after successful completion of the AMC examination process, until the verification has been confirmed.
Candidates who have previously obtained confirmed verification of their primary medical degree through the EICS will be required to provide the
AMC with their EICS number and sign the Authorisation for Release of Information Form to enable the AMC to obtain a copy of the verification
report from the EICS.
EICS NUMBER USMLE NUMBER
PRIVACY
Your privacy is respected by the AMC. Information collected by the AMC may be used for administering the assessment of overseas
trained specialists and provided to officers of the specialist colleges involved in specialist assessment, the respective employer and the
Medical Board of Australia.
The AMC privacy procedures are set out in a Privacy Policy statement which can be obtained from the AMC. If you have any privacy
concerns or would like to verify information held about you, please contact the Privacy Officer, Australian Medical Council Limited,
PO Box 4810, KINGSTON ACT 2604, Australia.
Consent to collect information
Signature Date
Day Month Year

Updated January 2013 Page 6 of 15
DECLARATION BY APPLICANT
Please print clearly in sections below and complete all fields
I, (Name)
of (Address)
(Occupation)
DO SOLEMNY AND SINCERELY DECLARE THAT:
 I am the person identified in the foregoing Specialist Application (A)
 I am the person who has signed below
 I have signed the Primary Source Verification of Medical Qualifications—Authorisation for Release of Information Form
 I have familiarised myself with the AMC’s requirements, procedures and policies as set out in relevant AMC publications and on its website,
as well as with its Privacy Policy
 The statements made, and the information provided, in this application form and in the certified documents attached are true and complete.
Signature of person making the Declaration and Consent to Collect Information
(applicant’s signature):
Please sign inside the box to ensure that the AMC is recording your full signature
Declared at the day of year
Name of city, town, suburb Date Month Year
or locality
Before me*
(Witness) Signature of person before whom the Declaration is made
Insert official title** of witness before whom the
Declaration is made
Insert address of witness before whom the Declaration is
made
Please print name of witness in BLOCK LETTERS
Contact number of witness.
* The person witnessing this Declaration must be the same person who certifies the documents of the applicant. If a different eligible witness is
used the certify the supporting documentation you must submit a statutory declaration explaining why a different witness was used and it must be
witnessed by the new eligible witness.
** The title of the witness must be written (e.g. Notary Public, Justice of the Peace).
Updated January 2013 Page 7 of 15
PRIMARY SOURCE VERIFICATION OF

MEDICAL QUALIFICATIONS

Authorisation for Release of Information Form
I hereby authorise:
1. The Australian Medical Council Limited (AMC) to submit my personal (identifying) information and my candidate
Information (documents in support of my medical credentials) to the Educational Commission for Foreign Medical
Graduates (ECFMG) for the purpose of verification and/or source verification in respect of my application.
2. ECFMG to retain such information in ECFMG’s database for the purposes of
a) addressing any further requests from AMC for verification and/or source verification in respect of my application
b) responding to any request sent to ECFMG from an authority other than AMC, as authorised by me, or directly from
me, to verify and/or source verify my credentials
c) internally accessing those portions of the data which are not personal information in order to verify credentials of other
persons from time to time.
I request and authorise every person, institution, professional licensing board of any state or country in which I hold or may
have held a license to practise my profession, hospital, clinic, government agency (local, state, federal or foreign), law
enforcement agency or other third parties and organisations, and their representatives, to release information, records,
transcripts and other documents, concerning my professional qualifications and competence, ethics, character and other
information pertaining to me, to ECFMG.
I further request and authorise that the requested information, documents and records be sent directly to:
Educational Commission for Foreign Medical Graduates
3624 Market Street
Philadelphia, PA
19104, U.S.A.
IMMUNITY AND RELEASE
I hereby extend absolute immunity to, and release, discharge and hold harmless from any and all liability:
a) ECFMG and AMC and their respective agents, representatives, directors and officers
b) other licensing boards, government agencies, institutions, hospitals and clinics providing information pursuant to this
authorisation, and their representatives, directors and officers
c) any third parties and organisations for any acts, communications, reports, records, transcripts, statements, documents,
recommendations or disclosures involving me, made in good faith and without malice, requested or received by ECFMG
or AMC or any other third party.
By my signature below, I acknowledge that information, documents and records required to be furnished by another
organisation, educational institution, hospital, individual or any person or groups of persons must be sent directly by such
persons to ECFMG. I understand that ECFMG will not accept such information, records or documents forwarded by me.
A photocopy or facsimile of this authorisation form shall be as valid as the original and valid from the date signed.
Date of signature

Day Month Year
Signature Securely glue in this square a current front-
view passport-sized colour photograph of
Ensure this signature is similar to the
yourself in the block below.
signature on the Application
Declaration. Please clearly print your full
Please sign inside the box to ensure the AMC is names on the back of this photo.
recording your full signature
PLEASE PRINT
Family name/Surname
The passport-sized photographs
MUST be:

in colour
First name good quality
no older than 12 months
no smaller than 35 mm x 45 mm
no larger than 40 mm x50 mm
no ink or marks on the edges
Middle initial, Suffix (e.g. Jr)
not too dark
not too light
Do NOT staple or tape
Date of birth
Please ensure your date of birth is written in full
(e.g 23 January 1970)

Updated January 2013 Page 8 of 15
Checklist for Specialist Application (A)
The following checklist will help you collate the required documents. If you do not provide these documents or if
the documents you provide are not clearly legible or in full, processing of your application will be delayed. For
details about the required documents, see the AMC website (www.amc.org.au).

Have you answered all questions on Specialist Application (A)?

Have you attached 2 current (no older than 12 months) colour passport-sized photographs with your name
printed clearly on the back? One is to be attached to Specialist Application (A) and the other to the Primary
Source Verification of Medical Qualifications—Authorisation for Release of Information Form. See the AMC
website for proof of identity requirements (www.amc.org.au).

Have you completed in full the Primary Source Verification of Medical Qualifications—Authorisation for
Release of Information Form and attached to it a current (no older than 12 months) colour passport-sized
photograph?

Have you included certified copies of your final ‘hang on the wall’ primary qualification and your specialist
qualification(s)?

Have you included certified copies of the English translations of your primary or specialist qualifications if
those qualifications are in a language other than English? The translations must have been done by an
authorised translation service. The AMC translation policy is available at
http://www.amc.org.au/index.php/ass/apps/trans.

Have you submitted certified evidence of your identity according to the AMC’s proof of identity requirements
available on the AMC website (www.amc.org.au)?

Has your documentation been certified, dated and signed (with name and title printed) by the same person
who witnessed your Specialist Application (A)? A list of eligible witnesses can be found on the information
sheet of the application package and on the AMC website (www.amc.org.au). If a different eligible witness
certified your documentation or witnessed your application, you must correctly complete a statutory
declaration to explain why a different witness was used.

Have you provided a statutory declaration or change of name documentation for any name variations in your
application or in any of the supporting documentation you are submitting? Please also state the name you
wish to use for AMC purposes.

Have you provided evidence of English language proficiency? If proof of your English language proficiency is
not provided, the AMC will require an explanation of why it has not been provided or an indication of when it
will be provided. Evidence of English language proficiency is required in accordance with the English
Language Skills Registration Standard of the Medical Board of Australia. The standard is available on the
Medical Board of Australia website (www.medicalboard.gov.au).

Have you included a cheque or money order or your credit card details for payment of the application fee?

Have you attached to any document that is in a language other than English an English translation conducted
by an authorised translation service or a professional translator? Has that authorised translator included their
details on the actual translation page or, if on a separate page, have they correctly bounded it (no staples)?

January 2013 Page 9 of 15
SPECIALIST APPLICATION (B)
SUMMARY OF BASIC MEDICAL TRAINING AND SPECIALIST TRAINING AND
EXPERIENCE
Please ensure that ALL sections of this form are completed, signed and dated in order to be accepted.
IDENTITY OF APPLICANT
Family name (Surname)
Given names
Date of birth Male Female
Day Month Year
Country of birth
PRIMARY MEDICAL QUALIFICATION
Primary qualification obtained
Date course completed Duration years
Day Month Year
Name of medical school issuing
the primary qualification
Country of training and issue Year awarded
PRINCIPAL/HIGHEST SPECIALIST QUALIFICATION
Specialist qualification obtained
Date course completed Duration years
Day Month Year
Name of medical school issuing
the specialist qualification
Country of training and issue Year awarded
INTERN TRAINING QUALIFICATIONS (If insufficient space, please provide information required in an attachment)
PERIOD
INSTITUTION ROTATIONS COVERED
From (full date) To (full date)

January 2013 Page 10 of 15