REGISTER FROM OUTSIDE OF NZ

Please fill in the following form. Required fields are in bold

Personal information

First name:

Middle name:

Last name:

Male

Female

Date of Birth:

Postal Address

Address:

City or Town:

Country:

Contact information

Home Phone:

Work Phone:

Fax:

Mobile:

Email:

Details

Qualifications (Primary & Postgraduate):

Emergency Contact Details:

Relevant Medical History:

Date(s) Available:

Duration:

Position sought:

Partner/Travel Companion if planning to seek work together:

To avoid confusion, please indicate any other NZ recruitment agency or hospital approached directly:

Registered with the Medical Council of NZ?:
Yes No

Immigration Status:
Visitor NZ Resident

Declaration

DECLARATION: I declare that the above supplied information is, to the best of my knowledge, true. I understand that my CV and references once supplied will be available to principals for the purpose of arranging employment.

I agree

REGISTER FROM OUTSIDE OF NZ

Please fill in the following form. Required fields are in bold

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