Modified ACEM CPD Program

Modified ACEM CPD Program

Participants working outside Australia and Aotearoa New Zealand
CPD participants working outside Australia and Aotearoa New Zealand are required to complete this application form for participation in the modified ACEM CPD program.

By completing this application, I acknowledge that
- I have been working outside of Australia and Aotearoa New Zealand for at least 12-months;
- I am not currently registered to practice medicine in Australia or Aotearoa New Zealand;
- I am required to complete the modified ACEM CPD program requirements by the end of the CPD year; and
- approval of my participation with the modified ACEM CPD program requirements is for the current CPD year only. I am required to reapply each subsequent year.
I acknowledge all of the above
Name*

First NameLast Name
Email*
example@example.com
Date*

DayMonthYear
Date
ACEM ID*
Country in which you will be working for the CPD year*
Have you ever been registered to practiced medicine in Australia or Aotearoa New Zealand?*

YesNo
When were you last registered to practice medicine in Australia or Aotearoa New Zealand?*

DayMonthYear
Date
Please attach evidence of current employment in the country named above with this application.*

Cancelof
Should be Empty: