AANZHPBA Training Program Application Form

Step 1 - Make a Payment

A payment of $450 is due immediately on submission of your application for the Post Fellowship Training Program. You will need to complete this step first.

Step 2 - Complete the Form

Before you commence Step 2, we recommend that you work from a saved version of your reply by copying and pasting into the relevant sections below. Be sure to have all the relevant documents ready to complete the application below IN ONE SITTING. This advice is to safeguard you against losing your uploaded information should there be a break in your internet connection or you accidentally navigate away from the page before sending.

First Name (Mandatory field)

Date of Birth (Mandatory field)

Email (Mandatory field)

Last Name (Mandatory field)

Gender

Phone (Mandatory field)

Address (Mandatory field)

____________________________________________________________

COMPULSORY REQUIREMENTS

FRACS: Please upload a copy of your certificate/letter. Be sure to title each file with 'YOUR NAME and DOCUMENT NAME'. (Mandatory field) -

I have attached my FRACS Certification above. (Mandatory field) Yes
I am a citizen OR permanent resident of Australia or New Zealand. (Mandatory field) Yes
___________________________________________________________

COVER LETTER (Maximum 500 Words).

Why do you believe you are a good candidate for selection into HPB training and a career in HPB surgery?
What are your ambitions in HPB surgery?
Future job prospects, (details of any proposed overseas training or research and some indication as to future career aspirations)

Cover Letter (Mandatory field)
___________________________________________________________

EMPLOYMENT DETAILS

Current Position (Mandatory field)
Previous Clinical Appointments
Registrations
_________________________________________________________

EDUCATION

Degrees awarded (Mandatory field)
Please use the following layout:
1. Degree - Date - University
2. Degree - Date - University
3. Degree - Date - University
and so on...
Prizes & Scholarships – Medical School and Surgical Training only
Please use the following layout:
1. Prize/Scholarship - Date - Institution
2. Prize/Scholarship - Date - Institution
3. Prize/Scholarship - Date - Institution
and so on...
Academic Appointments
Please use the following layout:
1. Title - Date - Institution
2. Title - Date - Institution
3. Title - Date - Institution
and so on...
Professional Memberships
________________________________________________________

RESEARCH

Please provide links where possible for ALL research documentation.
If you have an ORCID iD that you own and control, please list this -

Original manuscripts

Please enter using Vancouver format, beginning with the most recent and listing your name in bold type
Where applicable please enter a PubMED reference link.
Please do not enter planned publications or publications in preparation

Please list in order of significance and use the following layout:
1. Authors - Publication Title - Abbreviated Journal Title - Year, month, date of publication - Volume:Pages
2. Authors - Publication Title - Abbreviated Journal Title - Year, month, date of publication - Volume:Pages
3. Authors - Publication Title - Abbreviated Journal Title - Year, month, date of publication - Volume:Pages
and so on

Others (Letters, editorials, case reports, etc)

Published abstracts (Full reference required)

Grants
________________________________________________________

PRESENTATIONS
Please include only those presentations that you have personally given.

Podium
Please use the following layout:
1. Poster Title - Authors - Year - Conference - Location
2. Poster Title - Authors - Year - Conference - Location
3. Poster Title - Authors - Year - Conference - Location
and so on...

Poster
Please use the following layout:
1. Poster Title - Authors - Year - Conference - Location
2. Poster Title - Authors - Year - Conference - Location
3. Poster Title - Authors - Year - Conference - Location
and so on...

_________________________________________________________

TEACHING ACTIVITIES

_________________________________________________________

ADMINISTRATIVE ACTIVITIES

Administrative commitments and qualifications

_________________________________________________________

OTHER ACHIEVEMENTS

Other information we should know

Upload any other relevant documentation here. Be sure to title each file with YOUR NAME and DOCUMENT NAME.

_________________________________________________________

REFERREES

Please list at least 3 consultant surgeons as referees who are able to comment on your surgical training to date, your suitability for ANZHPBA training and your potential as an HPB and ANZHPBA surgeon. This should include at least 1 ANZHPBA member and an HPB surgeon (who is head of a Unit you have worked in previously). Please ensure you have informed your referees that you are applying for the ANZHPBA training program and that they may be contacted.

Referree One (Mandatory field)

Name

Title

Mobile Number

Referree Two (Mandatory field)

Name

Title

Mobile Number

Referree Three (Mandatory field)

Name

Title

Mobile Number

Referree Four

Name

Title

Mobile Number

Referree Five

Name

Title

Mobile Number

_________________________________________________________

CLINICAL PRIVILEGES

Have your Clinical Privileges and / or appointment at any hospital or day procedure centre ever been denied, reduced, suspended or revoked or have you had conditions attached to that appointment for any reason? (Mandatory field)YESNO

If YES, give dates and particulars

Have you ever been subject to an adverse finding or had conditions attached to your medical indemnity insurance policy or registration by a Medical Board? (Mandatory field) YESNO

If YES, give dates and particulars

Have there ever been any serious adverse findings made against you which would be relevant to your appointment (for example: breach of insurance/medical laws, professional misconduct, sexual assaults or assaults) by the health Insurance Commission, a Medical Board, a Health Care Complaints Commission/Body, a Coroner, a Court or any other professional, disciplinary or similar body? (Mandatory field)YESNO

If YES, give dates and particulars

Have you ever had limitations or conditions applied by your insurer/ indemnifier on your existing Indemnity policy? (Mandatory field)
YESNO

If YES, give dates and particulars

_________________________________________________________

DECLARATION

I declare that by submitting my application for a Post Fellowship Training position with ANZHPBA that the information contained in this Fellowship Application is true and correct.

Name (Mandatory field)

Date (Mandatory field)

I am aware that $450 will be due and payable by me to ANZHPBA Inc immediately on submission of my application for the Post Fellowship Training Program. (Mandatory field) YES

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