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 Regn no.
Regn expired
If within 2 years qualifications 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 *
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

EMPLOYMENT HISTORY

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

Current Other option
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 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
(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.)
Should be Empty:

Australian Orthoptic Board - Registration Application