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Your Personal Details
First Name: *
Surname: *
Your Contact Details
Street Address: *
Suburb: *
Postcode: *
State: *
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ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Phone -Home:
Phone -Mobile: *
Email Address:
Fax Number:
Your Professional Details
Are you currently registered as a Nurse in Australia? *
Yes
No
If not do you have a current Blood Collection Certificate? *
Yes
No
Are you an ANF member?
Yes
No
Have you in the last 3 years had clinical experience in taking?
ECG TRACES
Yes
No
BLOOD
Yes
No
SPIROMETRY
Yes
No
Have you had any experience in any of the following?
Mobile Pathology Collections?
Yes
No
Mobile Paramedical Examinations?
Yes
No
Please provide in point form a brief description of your recent (last 3yrs) professional work history.
Please list two clinical referees
Name:
Phone:
Name:
Phone:
Additional Information
Do you hold a current Drivers License? *
Yes
No
Do you have a Vehicle? *
Yes
No
Do you have access to the following equipment at home?
Computer
Yes
No
Printer
Yes
No
Scanner
Yes
No
Internet Access
Yes
No
Fax
Yes
No
Your Availability *
Less than 10 hrs a week
Less than 20 hrs a week
Less than 30 hrs a week
Thank you for your Application you will recieve a confirmation Email of your submission to your listed Email address