MIA Elective-Observership Application Form

Please complete details below:

Personal information

First Name *

Last Name *

Street Address *

Suburb *

State *

Postcode *

Mobile Phone *

Email Address *

Preferred starting month (if successful) *

What is your preferred duration of the observational placement? (Select) *

Program selection

Choose up to TWO secondary clinical disciplines to spend at one day per week (note: must differ from your primary discipline and is not guaranteed): *

Surgery

Medical Oncology

Pathology

Radiation Oncology

Dermatology

Please attach the following to your application (file types accepted are .doc, .docx, .jpg, .pdf, .ppt, .pptx):

Cover Letter *

Choose File

Current Resume *

Choose File

Evaluation of Performance *

Choose File

Medical Qualifications *

Choose File

Cost

The cost of the observational placement is:

$100 (AUD) non-refundable application fee
An additional $400 upon acceptance.

Please make initial payment of $100 by electronic transfer to the bank account below: ANZ Account – Melanoma Institute Australia BSB: 012-361 Account No.: 835633105 SWIFT: ANZBAU3M

Please include OP and your SURNAME as a payment reference.

Submission

I certify that the information contained within my application is complete and accurate to the best of my knowledge. I understand that any false or missing information may disqualify me from consideration for a position, or may constitute cause for termination, from the program.

Full Name *

Date Submitted *

Thank you for submitting your application for the Melanoma Institute Australia Elective/Observership Program. We will be in touch soon.

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