Regn Appln

Australian Orthoptic Board - Registration Application

AOB Registration is biennial - current term 1 July 2017 to 30 June 2019
Application type *

New Restore
Previous Registration no.
Registration expired
If within 2 years supporting documents NOT required unless requested
Name *

Title First Name Middle Name Last Name
Previous name/s

Address *



Suburb	State
Postcode	Country

Mailing address (if not as above)



Suburb	State
Postcode	Country

Personal email *

Confirmation Email
Alternate email

Confirmation Email
At least one phone number is required - mobile preferred.
Mobile no.
Home no.

Area Code Phone Number
Work no.

Area Code Phone Number

QUALIFICATIONS

My academic orthoptic qualifications are:
Have you received your degree certificate *

Yes No
Month & Year course completed *
My eQuals link to Degree Certificate OR if not yet conferred, to Academic Transcript
QUALIFICATION (1) *
Abbreviation
Institution *
Date conferred *
Upload copy of degree
Optional
QUALIFICATION (2)
Abbreviation
Institution
Date conferred
Upload copy of degree
Optional
APPLICATION - SIGNATURE
Date *

- Day - Month Year Date Picker Icon

EMPLOYMENT HISTORY

(If applicable)
When were you most recently employed in Orthoptics? *

Current
Over the past 3 years, how many years / months have you been employed in Orthoptics? *
Please provide a summary of orthoptic work undertaken in the past 5 years. (Date/duration, Employer, areas of practice.) *
Optional supporting documents (eg CV, references)
CPD PROGRAM

Participation in the CPD Program is compulsory to maintain registration and requires 50 points of approved CPD activity to be completed in the 2-year registration period.
DECLARATIONS
- I certify that to the best of my knowledge the information and documents provided are true and correct.
- I acknowledge having received a copy of the Regulations adopted by the AOB.
- I undertake to inform myself of my responsibilities as an orthoptist registered by the AOB and abide by its Regulations (including the continuing professional development program of the AOB) while I am registered and in active practice.
- I understand that my registration is liable to be cancelled or I am liable to be disciplined in the event of breach of any of the requirements referred to in the Regulations.
- I undertake to provide any further information referred to in the Regulations and understand that if I refuse to provide any of the information this may affect my registration.
DECLARATION - SIGNATURE
Date *

- Day - Month Year Date Picker Icon
(A copy of this form will be emailed to you to print, sign and return
by mail with certified copies of your qualifications if applicable.)
Mail to:

Australian Orthoptic Board
PO Box 1035
HAMPTON NORTH VIC 3188
Should be Empty:

Australian Orthoptic Board - Registration Application