Application for Limited Registration for Supervised Practice as a Physiotherapist ALRP 66

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Application for limited registrationfor supervised practiceProfession: Physiotherapy

ALRP-66

Part 7 Division 6 of the Health Practitioner Regulation National Law (the National Law)

Effective from: 3 June 2014 Page 1 of 14

This form is for applicants who do not qualify for general registration andwho wish to apply for limited registration to undertake supervised practicein Australia for the rst time, or if previously registered and there has beena substantial change in employment circumstances. Applicants must hold a valid Australian Physiotherapy Council (APC) InterimCerticate. Practice may only be undertaken up until the end date of the valid APC Interim Certicate.This application comprises: Part A: to be completed by the applicant Part B: to be completed by the supervisor, and Part C: to be completed by the applicant.

It is important that you refer to the Physiotherapy Board of Australias (theBoard) registration standards, codes and guidelines when completing the form.Registration standards, codes and guidelines can be found atwww.physiotherapyboard.gov.au

This application will not be considered unless it iscomplete and all supporting documentation hasbeen provided. Supporting documentationmust be certied inaccordance with the Australian Health Practitioner Regulation Agency(AHPRA) guidelines. For more information, seeCertifying documents in the Information and denitionssection of this form.

Privacy and condentialityThe Board and AHPRA are committed to protecting your personal information

in accordance with the Privacy Act 1988(Cth). The ways the Board and AHPRAmay collect, use and disclose your information are set out in the collectionstatement relevant to this application, available atwww.ahpra.gov.au/privacy .By signing this form, you conrm that you have read the collection statement. AHPRAs privacy policy explains how you may access and seek correction of

your personal information held by AHPRA and the Board, how to complain to AHPRA about a breach of your privacy and how your complaint will be dealtwith. This policy can be accessed atwww.ahpra.gov.au/privacy .

Symbols in this form Additional information

Provides specic information about a question or section of the form.

AttentionHighlights important information about the form.

Attach document(s) to this form Processing cannot occur until all required documents are received.

Signature requiredRequests appropriate parties to sign the form where indicated.

Mail document(s) directly to AHPRARequires delivery of documents by an organisation or the applicant.

Completing this form Read and complete all questions . Ensure thatall pages and required attachments are returned to AHPRA. Use a black or blue pen only. Print clearly inB L OC K L E T T E RS

Place X inall applicable boxes: DO NOT send original documents unless specied.

Do not use staples or glue, or afx sticky notes to your application.Please ensure all supporting documents are on A4 size paper.

PART A To be completed by the applicant

SECTION A:Personal details

The information items in this section of the application marked with an asterisk (*) will appear on the public register.

1. What is your name and dateof birth?

If you have ever beenformally known by anothername, or you are providingdocuments in another name,youmust attach proof of yourname change unless this hasbeen previously provided tothe Board.

For more information, seeChange of name in theInformation and denitions section of this form.

Title*MR MRS MISS MS DR OTHER SPECIFY

Family name*

First given name*

Middle name(s)*

Previous names known by (e.g. maiden name)

Date of birth D D / M M / Y Y Y Y


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2. What are your birth andpersonal details?

Country of birth

City/Suburb/Town of birth

State/Territory of birth (if within Australia) VIC NSW QLD SA WA NT TAS ACT

Sex*MALE FEMALELanguages spoken other than English (optional)*

SECTION B:Proof of identity

You must provide proof of your identity with this application The minimum requirements for overseas applicants, or those who have recently arrived in Australia, can be found in theAHPRAProof of identity requirements document under the heading What special circumstances apply to overseas applicantsor applicants who have recently arrived in Australia? This document is available at www.ahpra.gov.au/identity

You must provide evidence from category A, B, and C. Youmust only use each document once. If your evidence from category C or B does not include your residential address, youmust also provide evidence from category D.Please indicate on the chart below which piece of evidence you are submitting for each category and attach the certied copies ofdocuments to your application.

3. Which documents from eachcategory will you provide forproof of identity?

The documents providedmustmeet the following criteria:

At least one document must be

in the applicants current name. Your category B document must

have a recent photo. All documents must be ofcially

translated into English.For documents translated in Australia, the translatormust be accredited by NAATI see www.naati.com.au For documents translatedoverseas, see www.t-ift.org for a list of authorities who providecertied translations. Please referto Translating documents at

www.ahpra.gov.au/translate forfurther information. Australian birth certi cate

extracts are not accepted. If using your passport, a certi ed

copy of the identity informationpage (the photo page)must be provided.

All documents must be truecertied copies of the original.See Certifying documents in theInformation and denitions sectionof this form for more information.

Choose proof of identity documents to submit: (A document may only be used once for any category)

DocumentsCategory used:

DocumentsCategory used:

A B C A B C

Australian passport Medicare card NA NA

Overseas passport with current Aust. visa PAYG payment summary NA NA

Australian birth certicate NA Motor vehicle registration NA NA

Current Australian visa NA Financial institution statement NA NA

Australian Armed Services papers NA Taxation assessment notice NA NA

Travel documents with Aust. visa NA Health insurance card NA NA

Australian citizenship certicate NA Pension card NA NA

Australian driver licence NA Category D documents

Working with children check card NA A document from Category D is only required if yourCategory B or C document does not provide evidenceof your residential address.

Firearm or shooters licence NA

Student ID card NA International driver licence NA I have used a Category B or C document that

has my current residential addressProof of age card NA

Change of name certicate NA NA Mortgage papers

Australian marriage certicate NA NA Rate notices

Australian divorce papers NA NA Lease or tenancy agreement

Board registration certicate NA NA Utility account

Bank acct. details credit or ATM card NA NA Electoral enrolment card

Youmust attach a certied copy ofall proof of identity documents that you haveindicated above.


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SECTION C:Contact information

Once registered, you can change your contact information at any time. Please go towww.ahpra.gov.au and download and complete the change of address formCHDT-00 Request for change of address details on the register , or log in to your AHPRA account to change your details online.

4. What are your contact details?Provide your current contact details below place an next to your preferred contact phone number.Business hours

After hours

Mobile

Email

5. What is your residentialaddress?

When you are not yetpractising, or when you are

not practising the professionpredominantly at one address:

your residential addresswill be recognised asyour principal place ofpractice, and

the information itemsmarked with an asterisk (*)will appear on the publicregister as your principalplace of practice.

Refer to the question belowfor the denition of principal

place of practice.Residential addresscannotbe a PO Box.

Site/building and/or position/department (if applicable)

Address (e.g. 123 JAMES AVENUE; or UNIT 1A, 30 JAMES STREET)

City/Suburb/Town*

State or territory (e.g. VIC, ACT) /International province* Postcode/ZIP*

Country (if other than Australia)

6. Will the address of yourprincipal place of practice bethe same as your residentialaddress?

Principal place of practicefor a registered healthpractitioner is: the address at which you

will predominantly practisethe profession; or

your principal place ofresidence, if you are notpractising the professionor are not practising theprofession predominantlyat one address.

Principal place of practicecannot be a PO Box.

The information items markedwith an asterisk (*) will appearon the public register.

YES NO Provide your Australian principal place of practice below



City/Suburb/Town*

State/Territory* (e.g. VIC, ACT) Postcode*


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7. What is your mailing address? Your mailing address is usedfor postal correspondence

My residential address

My principal place of practice

Other(Provide your mailing address below)


Address/PO Box (e.g. 123 JAMES AVENUE; or UNIT 1A, 30 JAMES STREET; or PO BOX 1234)

City/Suburb/Town

State or territory (e.g. VIC, ACT) /International province Postcode/ZIP

Country (if other than Australia)

SECTION D:Qualication for the profession

8. What are the detailsof your qualication inphysiotherapy?

To be eligible for limitedregistration for supervisedpractice you mustdemonstrate to the Boardthat you qualify to practisephysiotherapy under limitedregistration in the healthprofession.To qualify, you must hold avalid APC Interim Certicate.

For more information, seeCertifying documents in theInformation and denitions section of this form.

Primary qualication and examinations/assessments

Title of qualication

Name of institution (University/College/Examining Body)

Country

Start date Completion date

M M / Y Y Y Y M M / Y Y Y Y Youmust attach an original certied copy of your qualication that indicates completion of a

course of study leading to a qualication in physiotherapy, and a certied copy of your valid APC Interim Certicate.

Additional qualication and examinations/assessmentsTitle of qualication

Name of institution (University/College/Examining Body)

Country

Start date Completion date

M M / Y Y Y Y M M / Y Y Y Y

Attach a separate sheet if your qualication details do not t in the space provided.


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SECTION E:Registration history9. What is your health

practitioner registrationhistory?

If you have been previouslyregistered outside of Australia, the Board requiresa Certicate of RegistrationStatus or Certicate ofGood Standing fromevery jurisdiction outside of Australia in which you arecurrently, or have previouslybeen registered as a healthpractitionerduring thepast ve years .

Most recent registrationState/Territory/Country

Profession

Period of registrationD D / M M / Y Y Y Y to D D / M M / Y Y Y Y

Additional registrationState/Territory/Country

Profession

Period of registration

D D / M M / Y Y Y Y to D D / M M / Y Y Y Y

If you have been previously registered outside of Australia, youmust arrange for originalCerticates of Registration Status or Certicates of Good Standing to be forwarded directly fromthe registration authority to your AHPRA state ofce.Refer towww.ahpra.gov.au/About-AHPRA/Contact-Us for your AHPRA state ofce address.

Attach a separate sheet if all your registration history does not t in the space provided.

SECTION F:Work history10. What is your full practice

history?

It is important that you refer toCurriculum vitae in the Information and denitions section of this form formandatory requirements of the CV. Your curriculum vitae will further inform the Board in relation to yourrecency of practice and registration history.

Youmust attach to your application asigned and dated curriculum vitae that describes yourfull practice history and any clinical or skills training undertaken.

SECTION G:Suitability statements Information required by the Board to assess your suitability for registration is detailed in the following questions. It is recommended

that you provide as much information as possible to enable the Board to reach a timely and informed decision.Please note that registration is dependent on suitability as dened in the National Law, and the requirements set out in the Boardsregistration standards. Refer towww.physiotherapyboard.gov.au/Registration-Standards for further information.

11. Do you have any criminalhistory in Australia?

It is important that you have a clear understanding of the denition of criminal history. For more information,see Criminal history in the Information and denitions section of this form.

YES NO

Provide a separate sheet with details of your criminal history in Australia and explanation ofcircumstances.

12. Do you have any criminalhistory in another country?

For more information,see Criminal history in theInformation and denitions

section of this form.

YES NO

Provide a separate sheet with details of your criminal history in another country and explanationof circumstances.

13. Have you previously beenregistered to practise asa physiotherapist in Australia?

If you have previously been registered to practise as a physiotherapist in Australia, you have met therequirements of the BoardsEnglish language skills registration standard . However, the Board may still needevidence of your English language skills. In such a case, the Board will contact you.

YES Go to question 17 NO Go to the next question


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14. Did you undertake andcomplete your secondaryeducation and your tertiaryqualications in theprofession, in English, in oneof the countries listed?

For more information, seeEnglish language skills in theInformation and denitions

section of this form.

Australia Canada New Zealand Republic of Ireland South Africa United Kingdom United States of America

YES NO Go to the next question

Attachment required below then go to question 17

Youmust submit a certied copy of the original evidence of having undertaken yoursecondary education in English.

15. Which of the Englishlanguage examinationslisted here have yousuccessfully completed?

Pass results must beobtained in one sitting.

International English Language Test System (IELTS) Academic module Test report form number:

The Board requires an IELTS Academic module score of at least 7 in each of the four components(listening, reading, writing and speaking).

Occupational English Test (OET)Candidate number:

- - The Board requires completion and an overall pass in the OET, with grades A or B in each of the fourcomponents (listening, reading, writing and speaking).

Youmust arrange for the testing authority to provide evidence of your successful completionof the Board-approved English language test directly to your AHPRA state ofce. AHPRA willverify your test results directly with the testing authority (e.g., by secure internet login).

16. Were your results from theabove-mentioned Englishlanguage examinationsobtained in the pasttwo years?

YES NO

Youmust attach evidence that you have actively maintained employment as a registered healthpractitioner, or been continuously enrolled as a student in an approved program of study, usingEnglish as the primary language of practice in one of the following countries: Australia Canada New Zealand Republic of Ireland

South Africa United Kingdom United States of America

17. Do you commit to havingappropriate professionalindemnity insurancearrangements in place forall practice undertaken duringthe registration period?

The Board requires all applicants for limited registration to have appropriate professional indemnityarrangements in place when practising. Applicants unable to meet this requirement are ineligible for registration.For more information, seeProfessional indemnity insurance in the Information and denitions section of this form.

YES NO

18. Do you commit to undertakesufcient continuingprofessional development, inaccordance with the BoardsContinuing professionaldevelopment registrationstandard , in order to maintaincompetence throughout theperiod of registration?

For more information, seeContinuing professional development in the Information and denitions sectionof this form.

YES NO

19. If you graduated more thanve years ago, have youpractised the professionin the past ve years?

For more information, seeRecency of practice and Practice in the Information and denitions section of this form.

YES NO/NA

Youmust provide documentary evidence of practice in the past ve years which demonstrates

your competence to practise the profession.


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20. Do you have an impairmentthat detrimentally affectsor is likely to detrimentallyaffect your capacity topractise the profession?

For more information, seeImpairment in the Information and denitions section of this form.

YES NO

Youmust attach to this application details of any impairments and how they are managed.

21. Is your registration in

any profession currentlysuspended or cancelled inAustralia (under the NationalLaw or a corresponding priorAct) or overseas?

YES NO

Youmust attach to this application details of any registration suspension or cancellation.

22. Have you previously had yourregistration cancelled, refusedor suspended in Australia(under the National Law or acorresponding prior Act) oroverseas?

YES NO

Youmust attach to this application details of any cancellation, refusal or suspension.

23. Has your registration everbeen subject to conditions,undertakings or limitations inAustralia (under the NationalLaw or a corresponding priorAct) or overseas?

YES NO

Youmust attach to this application details of any conditions, undertakings or limitations.

24. Are you disqualied fromapplying for registration,or being registered, in anyprofession in Australia(under the National Law,a corresponding prior Actor a law of a co-regulatory jurisdiction), or overseas?

Co-regulatory jurisdiction means a participating jurisdiction (of the National Law) in which the Act applying (theNational Law) declares that the jurisdiction is not participating in the health, performance and conduct processprovided by Divisions 3 to 12 of Part 8 (of the National Law).

YES NO

Youmust attach to this application details of any disqualications.

25. Have you been, or are youcurrently, the subject ofconduct, performance orhealth proceedings whilstregistered under the NationalLaw, a corresponding priorAct, or the law of another jurisdiction in Australiaor overseas, where thoseproceedings were notnalised?

YES NO

Youmust attach to this application details of any conduct, performance or health proceedings.

SECTION H:Details of the supervised practice position

26. What are the details of thesupervised practice position?

Practitioners with limited registration for supervised practise must maintain their employment in the designatedposition. If there is any change to the position in which you are working you will be required to submit a newapplication for registration to the Board.

As specied in the Boards supervision guidelines, youmust attach to this application: agreements/undertakings (Form A), and Supervised Practice Plan (Form B)The guidelines can be found atwww.physiotherapyboard.gov.au/Codes-Guidelines


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SECTION I:Details of the APC Interim Certicate27. What is the expiry date of your

APC Interim certicate?Expiry date of APC Interim certicate

D D / M M / Y Y Y Y

Youmust attach to this application a certied copy of your APC Interim certicate.

SECTION J:Obligations and consent Before you sign and date this form, make sure that you have answered all of the relevant questions correctly and read the statements below.

An incomplete form may delay processing and you may be asked to complete a new form. For more information, see the Information and denitionssection of this form.

Obligations of registered health practitionersThe National Law pt 7 div 11 sub-div 3 establishes the legislative obligations ofregistered health practitioners. A contravention of these obligations, as detailed at points1, 2, 4, 5, 6 or 8 below does not constitute an offence but may constitute behaviour forwhich health, conduct or performance action may be taken by the Board. Registeredhealth practitioners are also obligated to meet the requirements of their Board as

established in registration standards, codes and guidelines.Continuing professional development1. A registered health practitioner must undertake the continuing professional

development required by an approved registration standard for the health professionin which the practitioner is registered.

Professional indemnity insurance arrangements2. A registered health practitioner must not practise the health profession in which

the practitioner is registered unless appropriate professional indemnity insurancearrangements are in force in relation to the practitioners practice of the profession.

3. A National Board may, at any time by written notice, require a registered healthpractitioner registered by the Board to give the Board evidence of the appropriateprofessional indemnity insurance arrangements that are in force in relation to thepractitioners practice of the profession.

4. A registered health practitioner must not, without reasonable excuse, fail to complywith a written notice given to the practitioner under point 3 above.

Notice of certain events5. A registered health practitioner must, within 7 days after becoming aware that a

relevant event has occurred in relation to the practitioner, give the National Boardthat registered the practitioner written notice of the event.Relevant event meansa) the practitioner is charged, whether in a participating jurisdiction or elsewhere,

with an offence punishable by 12 months imprisonment or more; orb) the practitioner is convicted of or the subject of a nding of guilt for an

offence, whether in a participating jurisdiction or elsewhere, punishable byimprisonment; or

c) appropriate professional indemnity insurance arrangements are no longer inplace in relation to the practitioners practice of the profession; or

d) the practitioners right to practise at a hospital or another facility at which healthservices are provided is withdrawn or restricted because of the practitionersconduct, professional performance or health; or

e) the practitioners billing privileges are withdrawn or restricted under theHumanServices (Medicare) Act 1973 (Cth) because of the practitioners conduct,professional performance or health; or

f) the practitioners authority under a law of a State or Territory to administer,obtain, possess, prescribe, sell, supply or use a scheduled medicine or class ofscheduled medicines is cancelled or restricted; or

g) a complaint is made about the practitioner to the following entities(i) the chief executive ofcer under theHuman Services (Medicare) Act 1973

(Cth);(ii) an entity performing functions under theHealth Insurance Act 1973 (Cth);(iii) the Secretary within the meaning of theNational Health Act 1953(Cth);(iv) the Secretary to the Department in which theMigration Act 1958 (Cth) is

administered;(v) another Commonwealth, State or Territory entity having functions relating

to professional services provided by health practitioners or the regulation ofhealth practitioners.

h) the practitioners registration under the law of another country that provides

for the registration of health practitioners is suspended or cancelled or madesubject to a condition or another restriction.

Change in principal place of practice, address or name6. A registered health practitioner must, within 30 days of any of the following changes

happening, give the National Board that registered the practitioner written notice ofthe change and any evidence providing proof of the change required by the Board

a) a change in the practitioners principal place of practice;b) a change in the address provided by the registered health practitioner as the

address the Board should use in corresponding with the practitioner;c) a change in the practitioners name.

Employers details7. A National Board may, at any time by written notice given to a health practitioner

registered by the Board, ask the practitioner to give the Board the followinginformationa) information about whether the practitioner is employed by another entity;b) if the practitioner is employed by another entity

(i) the name of the practitioners employer; and(ii) the address and other contact details of the practitioners employer.

8. The registered health practitioner must not, without reasonable excuse, fail tocomply with the notice.

ConsentI consent to the Board and AHPRA making enquiries of, and exchanging information with,the authorities of any Australian state or territory, or other country, regarding my practiceas a health practitioner or otherwise regarding matters relevant to this application.I authorise the Board to obtain my criminal history in Australia and overseas.I understand that: a complete criminal history, including resolved and unresolved charges, spent

convictions, and ndings of guilt for which no conviction was recorded,will be released to the Board, and

information will be extracted from this form and used for the purpose of criminalhistory checking. This information may be used by Australian police services forlaw enforcement purposes including the investigation of any outstanding criminaloffences.

I acknowledge that: the Board may validate documents provided in support of this application as

evidence of my identity, and failure to complete all relevant sections of this application and to enclose all

supporting documentation may result in this application not being accepted.I undertake to comply with all relevant legislation and Board registration standards,codes and guidelines.I conrm that I have read the privacy and condentiality statement for this form.I declare that:

the above statements, and the documents provided in support of this application,are true and correct, and I am the person named in the attached documents.I make this declaration in the knowledge that a false statement is grounds for the Boardto refuse registration.I am aware that personal information that I provide may be given to a third party forregulatory purposes, consistent with the National Law.

Signature of applicant

SIGN HEREName of applicant

Date

D D / M M / Y Y Y Y


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PART B To be completed by the supervisor

SECTION K:Supervisor details

28. What are the details of thesupervisors?

A contact person and emailaddress must be provided for

receipt of notications. Details of the supervisor

(who meets the requirementsdened in the Boardssupervision guidelines) mustalso be provided.

Provide supervisor 1 details below

MR MRS MISS MS DR OTHER SPECIFY Family (legal) name of supervisor 1

First given name

Address/PO Box(e.g. 123 JAMES AVENUE; or UNIT 1A, 30 JAMES STREET; or PO BOX 1234)

City/Suburb/Town

State/Territory (e.g. VIC, ACT)

Contact phone number

Postcode

Mobile

Email

Provide supervisor 2 details below (if applicable)

MR MRS MISS MS DR OTHER SPECIFY Family (legal) name of supervisor 2

First given name

Address/PO Box(e.g. 123 JAMES AVENUE; or UNIT 1A, 30 JAMES STREET; or PO BOX 1234)

City/Suburb/Town

State/Territory (e.g. VIC, ACT)

Contact phone number

Postcode

Mobile

Email


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29. What are the details of thepractice location?

Name of practice location

Site/Building (if applicable)


City/Suburb/Town

State/Territory (e.g. VIC, ACT) Postcode

Contact detailsContact phone number

Email

30. What are the names andaddresses of all sites ofpractice for which limitedregistration is being sought?



City/Suburb/Town




City/Suburb/Town



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City/Suburb/Town


Attach a separate sheet of the names and addresses of additional sites that do not t within thespaces provided.

SECTION L:Supervisors consent

I declare that the information provided in this document (including supervision and training details) is true and correct.I conrm that the physiotherapist (applicant) named below has been formally offered the position as described in this applicationI undertake to be the applicants principal supervisor and to provide a level of supervision as stated in the agreed supervised practice plan and as otherwisedetermined from time to time by the Board.I further undertake to: ensure that the applicant is practising safely and is not placing the public at risk observe the applicants work, conduct reviews, periodically conduct performance reviews and identify and address any problems as per the requirement

of the Boards Supervision Guidelines

notify the Board immediately if I have concerns about the applicants clinical performance, health or failure to comply with supervision requirements ensure that the applicant practises in accordance with work arrangements approved by the Board obtain approval of the Board for any proposed changes to work arrangements before they are implemented inform the Board if I am no longer able to undertake the role of the applicants supervisor provide supervision reports to the Board in a form approved by the Board at intervals as determined by the Board.

Name of applicant

Date

D D / M M / Y Y Y Y

Name of supervisor

Registration number

P H YSignature of supervisor

SIGN HERE


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Credit/Debit card payment slip please ll out

Amount payable

$

Visa or MasterCard number

Expiry date

M M / Y Y

Name on card

Cardholders signature

SIGN HERE

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PART C To be completed by the applicant

SECTION M:Payment

You are required to payboth an application fee and a registration fee.

Your required payment is detailed below:Use the table below to select your application fee and registration fee. Your registration fee depends on your principal place of practice, asapplicants whose principal place of practice is New South Wales are entitled to a rebate from the NSW Government.

Application fee: Registration fee: Amount payable:

$179 + $ INSERT FEE = $ INSERT FEERegistration fee $179 Applicantsmust pay 100% of the stated fees

at the time of submitting the application.Registration fee for NSW registrants $158

Registration Period

The annual registration period for the physiotherapy profession is from1 December to 30 November.If your application is made between 1 October and 30 November this year , you will be registered until 30 Novembernext year .Refund rules

The application fee is non-refundable. The registration fee will be refunded if the application is not approved.

31. How are you paying your fees? Payment by cheque, money

order or bank draft must be in Australian currency, drawn onan Australian bank.

A receipt will be provided.

Mark one box below only Visa or MasterCard Cash/EFTPOS

Complete credit/debit card payment slip below (only available if paying in person)

Cheque/Money order/Bank draft

Youmust attach cheque or money orderpayable to the Australian Health Practitioner

Regulation Agency.On the back of the cheque, money order or bank draft, youmust write: your name, and your registration number.


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SECTION N:Checklist

Have the following items been attached or arranged, if required?

Additional documentation Attached

Question 1 Evidence of a change of name

Question 3 Certied copies of all documents that provide sufcient evidence of your identity

Question 8 Original certied copy of your qualication

Question 8 A certied copy of your APC Interim Certicate

Question 8 A separate sheet with additional qualication details

Question 9 Certicate of Registration status or Certicate of Good Standing has been requested from relevant authority

Question 9 A separate sheet with additional registration details

Question 10 Your curriculum vitae

Question 11 A separate sheet with an explanation of circumstances of your criminal history in Australia

Question 12 A separate sheet with an explanation of circumstances of your criminal history overseas

Question 14 A certied copy of the original evidence of having undertaken your secondary education in English

Question 15 Evidence of the successful completion of an approved English language test has been requested from relevant authority

Question 16 Evidence that you have actively maintained employment using English as the primary language of practice

Question 19 Documentary evidence of practice in the past ve years

Question 20 A separate sheet with your impairment details

Question 21 A separate sheet with your current suspension or cancellation details

Question 22 A separate sheet with your previous cancellation, refusal or suspension details

Question 23 A separate sheet with your conditions, undertakings or limitations details

Question 24 A separate sheet with your disqualication details

Question 25 A separate sheet with your conduct, performance or health proceedings

Question 26 Completed documentation as required in the Boards supervision guidelines

Question 27 A certied copy of your APC Interim certicate

Question 30 A separate sheet of the names and addresses of additional sites

Payment

Application feeRegistration fee

If paying by cheque/money order/bank draft, your name and registration number are written on the back

Please post this form withpayment and requiredattachments to:

AHPRAGPO Box 9958IN YOUR CAPITAL CITY(refer below)

You may contact AHPRA on1300 419 495 or you can lodge an enquiryat www.ahpra.gov.au

Sydney NSW 2001 Canberra ACT 2601 Melbourne VIC 3001 Brisbane QLD 4001 Adelaide SA 5001 Perth WA 6001 Hobart TAS 7001 Darwin NT 0801


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Application for Limited Registration for Supervised Practice as a Physiotherapist ALRP 66

Documents

Transcript of Application for Limited Registration for Supervised Practice as a Physiotherapist ALRP 66