Short-Term Training application form

Short-Term Training application form
This form is to be completed by a Specialist International Medical Graduate (SIMG) or International Medical Graduate (IMG) who is seeking to obtain medical registration from the Medical Board of Australia (MBA) for employment in a Short-Term Training (STT) position in an Australian emergency department. These applications require assessment by the College of the SIMG/IMG's international qualifications and experience and the suitability of the position.

See the Short-Term Training page on the ACEM website for further information.

Short-Term Training (STT) is usually considered to be up to 24 months.
Application type
The application fees can be found on the ACEM website.
Applicant details
Name

Given name/sLast Name
Previous name/s known by
Title
Date of birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Residential Address

Street Address

Street Address Line 2

CityState

Post CodeCountry
Mailing Address

Street Address

Street Address Line 2

CityState

Post CodeCountry
Email
example@example.com
Mobile phone number
Other phone number
AMC Candidate Number
Please attach documents

AAMC-30 form (relevant sections completed) and Curriculum Vitae (as per AHPRA requirements)
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Position details
Employer
Locations
Each location must be listed and separated by commas.
Position title
Proposed commencement date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Proposed end date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Please attach documents

Letter of Offer from employer, position description, training plan (on employer letterhead), SPPA-30 form (relevant sections completed) and statement of intent (at the time of registration you have no intention of making further applications for registration at the end of the specified training period).
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Qualifications
Primary medical qualification
Qualification
Country of training
Training commencement

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Training end date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Awarding institute
Date awarded

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Duration of training
Please attach a copy of your primary qualification

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Specialist emergency medicine training qualification
Qualification
Country of training
Training commencement

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Training end date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearLeave blank if training is not completed
Awarding institute
Date awarded

DayMonthYear
2 digit day, 2 digit month, 4 digit yearLeave blank if training is not completed
Duration of training
Does this specialist qualification lead to eligibility for attaining specialist registration in your country of training?
Please attach a copy of your specialist qualification

If you are still in training and likely to be no more than 2 years away from completing your specialist training, please attach an official statement from your training institution confirming your status/progress as a trainee
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Please attach a copy of your specialist qualification and evidence of specialist registration or eligibility for specialist registration upon attaining the specialist qualification

If you are still in training and likely to be no more than 2 years away from completing your specialist training, please attach an official statement from your training institution confirming your status/progress as a trainee
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Additional information
Please include details of any other information relevant to this application
Declaration
I, declare that:
- I am the person identified in the Application for Short-Term Training
- I am the person who has signed below
- I have familiarised myself with the requirements, procedures and policies as set out in relevant MBA and College Regulations regarding Short-Term Training
- I do not have or have been made aware of any complaints made against me, charged or convicted of any criminal offence or subjected to any restriction on practice under the law or regulations in any country
- The statements made, and the information provided, in this application form and in the documents attached are true and complete
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Payment

SIMG Short-Term Application Form

$851.00 AUD Quantity

Total

Debit or Credit Card
Credit Card Number	Security Code
Expiration Month	Expiration Year

Should be Empty:

Short-Term Training application form

Applicant details

Position details

Qualifications

Declaration

Payment

*