Document ID: chunk:federal_register_of_legislation:F2017L01293:clause:2_19:p3
Version: federal_register_of_legislation:F2017L01293
Segment Type: clause
Provision Reference: sch 2 cl 19 (pt 3/4)
Character Range: 56250–60073

to become an approved pathology authority and hereby give the undertaking recorded in this Schedule to the Minister. I/we acknowledge that a breach of this undertaking may be referred to a Medicare Participation Review Committee (MPRC) in accordance with the Act and, pursuant to section 124FB of the Act, the MPRC may make a number of determinations including that Medicare payments should not be payable for up to 5 years.

I/we request the Minister or a delegate of the Minister to accept the undertaking under section 23DF of the Act. I/we certify that all information in this application is true and correct.

Name:       ________________________  Name:       ________________________
Position:       ________________________  Position:    ________________________
Signature:     ________________________  Signature:  ________________________
Date:       ________________________  Date:          ________________________
Address:              Address:

Witness (see 'Applicant Instructions' for detail on witness requirements & execution of undertaking)

I, ______________________, hereby assert that the applicant is known to me or, if not known, I am satisfied as to her/his identity and did witness the signing of this instrument before me on this day.

Signature:

Date:

Address:

Partnership
Name, ABN (if applicable) and signature of each partner and date signed.

_________________, ___________________, ________________, ______.
    (name in block letters)          (ABN if applicable)     (signature)      (date)

_________________, ___________________, ________________, ______.
(name in block letters)          (ABN if applicable)     (signature)      (date)

_________________, ___________________, ________________, ______.
(name in block letters)          (ABN if applicable)     (signature)      (date)

_________________, ___________________, ________________, ______.
(name in block letters)          (ABN if applicable)     (signature)      (date)

_________________, ___________________, ________________, ______.
(name in block letters)          (ABN if applicable)     (signature)      (date)

_________________, ___________________, ________________, ______.
(name in block letters)          (ABN if applicable)     (signature)      (date)

_________________, ___________________, ________________, ______.
(name in block letters)          (ABN if applicable)     (signature)      (date)

_________________, ___________________, ________________, ______.
(name in block letters)          (ABN if applicable)     (signature)      (date)

_________________, ___________________, ________________, ______.
(name in block letters)          (ABN if applicable)     (signature)      (date)

_________________, ___________________, ________________, ______.
(name in block letters)          (ABN if applicable)     (signature)      (date)

_________________, ___________________, ________________, ______.
(name in block letters)          (ABN if applicable)     (signature)      (date)

_________________, ___________________, ________________, ______.
(name in block letters)          (ABN if applicable)     (signature)      (date)

_________________, ___________________, ________________, ______.
(name in block letters)          (ABN if applicable)     (signature)      (date)

_________________, ___________________, ________________, ______.
(name in block letters)          (ABN if applicable)     (signature)      (date)

_________________, ___________________, ________________, ______.
(name in block letters)          (ABN if applicable)     (signature)      (date)

All partners to sign. If insufficient space, this page can be copied and signed. If a partner is a corporation, show company name and position held by natural person authorised and signing on behalf of the company.