Applicant's Surname:
(Req.)
Given Names:
(Req.)
Principal Practice Address:
(Req.)
Mailing Address:
(Req.)
Telephone:
(Req.)
Facsimile:
(Req.)
Mobile:
(Req.)
Email:
(Req.)
Qualifications:
(Req.)
NSW Medical Board Registration Number:
(Req.)
Provider Number:
(Req.)
Restrictions (if applicable):
(Opt.)

In applying for membership of the Division, the applicant agrees to abide by the constitution of the Division. The principal requirements under the constitution are as follows.

  1. Members must be registered to practice by the NSW Medical Board.
  2. Members must be practising as a general practitioner within the Division area.
  3. The decision of the Board of the Division shall be final in regard to an applicant meeting the above requirements.