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Psychiatry Interest Forum application form – medical practitioners

Form for medical practitioners to apply for membership of the Psychiatry Interest Forum.
Please note, you must be registered to practice in Australia or New Zealand and have an AHPRA or MCNZ registration number to apply.

Not a medical practitioner? Use the Psychiatry Interest Forum application form for students instead.

Recently graduated or changed your details? No need to reapply, login and update your details online.
 

About the Psychiatry Interest Forum

Declaration

By submitting this application, I acknowledge, agree and declare that:

1. The information I have provided in this application form is current, true and correct;

2. I am registered as a medical practitioner with the Australian Health Practitioner Regulation Agency or the Medical Council of New Zealand.  I am not, or have not previously been, a RANZCP fellow, trainee, non-RANZCP psychiatrist or an international medical graduate on the pathway to RANZCP Fellowship.

3. I consent to the RANZCP collecting, storing and using my personal information for the purpose of administering my participation and providing services to me as well as (unless I have 'opted out' by contacting the Membership Services Department) sending me advertising information by itself or its related committees.

Personal details


Title*

First name*

Surname*

Gender


Are you of Aboriginal, Torres Strait Islander or Māori origin?

Contact details

Address line 1*
(maximum 40 characters)

Address line 2
(maximum 40 characters)

Suburb/town*

State
(leave empty if outside Australia)

Postcode
(leave empty if outside Australia or New Zealand)


Country*

Mobile phone number*

Email address*

Please retype email address*

Registration and qualifications

Type of medical practitioner*

AHPRA/MCNZ registration number
(include letters and zeros)*

Main qualifications*
(select any that apply)








 
Other qualifications (select any that apply)



























 

Current occupation

Employer
(ie. Health Service/District)

Position

Other information

Which areas of psychiatry practice are you interested in?
(choose any that apply)











 
Other: 
 
What prompted you to apply to join the forum?
(choose any that apply)


 
Other: 
 
How did you hear about the forum?
(choose any that apply)


 
Other: