APPLICATION FORM
NAME: _____________________________________________________
ADDRESS: __________________________________________________
 TELEPHONE(S): _____________________________________________
EMAIL: _____________________________________________________
DATE JOINED AMAC: ________________________________________
ACCREDITED HOURS: _______________________________________
EXAMINATION APPLIED FOR: PART 1 PART 11
Please circle ONE only as it is no longer possible to do Part 1 and Part 11 in the same year.
Please include:
1) your LOG CARD giving details of the courses/seminars/meetings attended.
2) details of hours accredited for Preceptor attendance, case commentaries and case documentation.
3) evidence of recency and frequency of practice eg data from HIC (without patient identifiers)
4) chequepayable to AMAC for the appropriate amount and send to:
Dr. Ann Miller, P.O.Box 1012 , Sale , Victoria 3850
Ph: fax: email: tarkaan |
