CPPSA membership application

Membership category -- Select -- Ordinary Trainee

Personal details

Name

Title

First name

Last name

Preferred first name

(if different from First name above)

Gender Prefer not to say Female Male Gender diverse Ethnicity -- Select -- Aboriginal Torres Strait Islander Aboriginal and Torres Strait Islander Māori Other Job title -- Select -- Career Medical Officer Community Paediatrician Emergency Physician Forensic Paediatrician General Paediatrician General Practitioner General Surgeon Neurosurgeon Ophthalmologist Orthopaedic Surgeon Pathologist Plastic Surgeon Psychiatrist Radiologist Registrar/Fellow with FRACP (or equivalent) Trainee in a specialist program Other...

CV

Upload your latest CV.
Your CV will only be used for the purpose of approving this application and will not be saved.
Click this button and select your CV file on your computer, e.g. a PDF file.

Contact details

Email address

Address

Country -- Select -- Australia New Zealand Address

City

State -- Select -- ACT NSW NT QLD SA TAS VIC WA

Postcode

Phone

Preferred number for CPPSA communications

Alternative numbers:

Mobile

Work

Other

Nomination

Please enter the name of a current CPPSA member who has agreed to support your application. If you need help to find a nominator, please contact us.

Nominator

Declaration

I declare that the information above is true and accurate, and I have read and agree to all of the following documents. (The links open in a new tab):

• Vision, Mission and Values of CPPSA
• CPPSA Constitution
• CPPSA Code of Conduct

I agree with this Declaration statement.