Registration Form

You are required to complete and submit the below form once you have been appointed as an AGES Trainee.

This online form will be automatically submitted to the AGES Secretariat.

Trainee Details
Name*
Prefix First Last
Address*
Street Address City State Postal Code Country
Phone*
Email*

You will receive an automated confirmation email once this form has been submitted.
Registration
Are you a registered medical practitioner in Australia or New Zealand?*
- Yes
- No
Are you a registered specialist in Australia or New Zealand?*
- Yes
- No
Education

Please list your education history:*

Degree / Qualifications	Organisation	Date

AGES Fellowship Position
Please list the details of your AGES Fellowship Position*
Training Unit Training Director Date of Engagement Commencement Date (mm/yyyy)
Affiliation

Please list details of any medical associations you are a member of:

Associate/Member/Fellow	Organisation/Association

Are you a member of the AGES Society?*
- Yes
- No
I certify that I have no restrictions, conditions or any other limitations on my medical registration(s) and that the information contained in this application is true and accurate and I provide the acknowledgements above. Whilst AGES is facilitating the administration of fellowship positions in the AGES Training Program in Gynaecological Endoscopy to be offered by accredited training units, the responsibility for education, training and assessment will rest solely with the individual Unit offering the position.
Trainee Signature*
Date*
DD slash MM slash YYYY
Training Director
Training Director Details*
Director Name Institution Country
Training Director Signature*
Date*
DD slash MM slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

Trainee Details