PERSONAL DETAILS *Demotes MANDATORY – this information must be completed if registration is to be completed Date (day/month/year) * Mr Mrs Ms Miss Doctor First Name * Middle Name(s) Last Name * Gender * Male Female Ethnicity NZ European NZ Maori Other European Define: Pacific Peoples Define: Asian Define: Middle Eastern Define: American Define: African Define: Other Define: CONTACT DETAILS When completing this section, please ensure that you provide the best details to easily contact you. *Demotes MANDATORY field – this information must be completed if registration is to be completed Contact Details – Phone numbers * Home Work Work mobile Personal mobile Contact Details – Email Address * Personal Alternative Personal Work Contact Details – Address * Number and Street Suburb City Postcode
Doctor – Other Surgeon Define: Doctor – Paediatrician Doctor – Pathologist / Disaster Victim Identification Doctor – Psychiatrist Doctor – Public Health Doctor – Radiologist Doctor – Registrar Define: Doctor – RMO / House Officer Define: Emergency Manager Emergency Management Logistician Enrolled Nurse Define Speciality Midwife LMC Hospital Pharmacist Psychologist Public Health HPO MOoH Other –define: Radiographer Registered Nurse – District / Community Registered Nurse – ED / Emergency Care Registered Nurse – Flight Nurse Registered Nurse – General Practice Nursing Registered Nurse – General Medical Registered – General Surgical Registered Nurse – ICU Registered Nurse – Mental Health Registered Nurse – Orthopaedic Registered Nurse – Paediatric Registered Nurse – Public Health Registered Nurse – Theatre Registered Nurse – Wound Care Registered Nurse – other Define: Social Worker – Mental Health Social Worker – other Define: Technician – Anaesthetic Technician – Laboratory Define:
Technician – Mortuary Define: Technician - Communications Define: Technician – Pharmacy Technician – other Define: Other Define: Professional Category – Second Administration Define: DHB General Practice Allied Health Define: Ambulance Paramedic Caregiver Aged Care Palliative Care DSS Doctor – Anaesthetist Doctor – General Practitioner Doctor – General Surgeon Doctor – Obstetrician Doctor – Orthopaedic Surgeon Doctor – Paediatric Surgeon Doctor – Plastic Surgeon Doctor – Other Surgeon Define: Doctor – Paediatrician Doctor – Pathologist / Disaster Victim Identification Doctor – Psychiatrist Doctor – Public Health Doctor – Radiologist Doctor – Registrar Define: Doctor – RMO / Officer Define: Emergency Manager Emergency Management Logistician Enrolled Nurse Define Speciality Midwife LMC Hospital Pharmacist Psychologist Public Health HPO MOoH Other –define: Radiographer Registered Nurse – District / Community Registered – ED / Emergency Care
Registered Nurse – Flight Nurse Registered – General Practice Nursing Registered – General Medical Registered Nurse – General Surgical Registered Nurse – ICU Registered Nurse – Mental Health Registered – Orthopaedic Registered – Paediatric Registered – Public Health Registered – Theatre Registered – Wound Care Registered Nurse – other Define: Social Worker – Mental Health Social Worker – other Define: Technician – Anaesthetic Technician – Laboratory Define: Technician – Mortuary Define: Technician - Communications Define: Technician – Pharmacy Technician – other Define: Other Define: Professional Category – Third Administration Define: DHB General Practice Allied Health Define: Ambulance Paramedic Level: Caregiver Aged Care Palliative Care DSS Doctor – Anaesthetist Doctor – General Practitioner Doctor – General Surgeon Doctor – Obstetrician Doctor – Orthopaedic Surgeon Doctor – Paediatric Surgeon Doctor – Plastic Surgeon Doctor – Surgeon Define: Doctor – Paediatrician
Doctor – Pathologist / Disaster Victim Identification Doctor – Psychiatrist Doctor – Public Health Doctor – Radiologist Doctor – Registrar Define: Doctor – RMO / House Officer Define: Emergency Manager Emergency Management Logistician Enrolled Define Speciality Midwife LMC Hospital Pharmacist Psychologist Public Health HPO MOoH Other –define: Radiographer Registered – District / Community Registered Nurse – ED / Emergency Care Registered Nurse – Flight Nurse Registered Nurse – General Practice Nursing Registered – General Medical Registered Nurse – General Surgical Registered – ICU Registered Nurse – Mental Health Registered Nurse – Orthopaedic Registered Nurse – Paediatric Registered – Public Health Registered Nurse – Theatre Registered – Wound Care Registered Nurse – other Define: Social Worker – Mental Health Social Worker – other Define: Technician – Anaesthetic Technician – Laboratory Define: Technician – Mortuary Define: Technician - Communications Define:
Basic Understanding Native Good Fair Basic Reading Native Good Fair Writing Native Good Fair Basic Language 3 – other than English Name: Language 3 – Please and indicate level of competency Speaking Native Good Fair Basic Understanding Native Good Fair Basic Reading Native Good Fair Writing Native Good Fair Basic DRIVER LICENCE DETAILS *Demotes MANDATORY field – this information must be completed if registration is to be completed Current NZ Driver Licence * Yes No Driver Licence Number * Driver Licence Type * Learners Restricted Full Driver License Expiry Date * (Day/month/year)