application for provisional registration apro 76

8/10/2019 Application for Provisional Registration APRO 76

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*APRO-761*

Application for provisional registrationProfession: Psychology

APRO-76

Part 7 Division 6 of the Health Practitioner Regulation National Law (the National Law)

Effective from: 9 September 2014 Page 1 of 12

This form is for individuals applying for provisional registration to enable themto undertake the period of supervised practice required to be eligible to apply

for general registration.

An applicant for provisional registration must have completed, within the

past ten years, a four-year sequence of study in psychology accreditedby the Australian Psychology Accreditation Council (APAC), or a sequence

of study that has been assessed by the Psychology Board of Australias (the

Board) accreditation authority as substantially equivalent.

There are four distinct pathways available for completion of the requiredsupervised practice:

The higher degree pathway:a fifth and sixth-year APAC accreditedhigher degree leading to general registration (i.e. Masters, Doctorate, or

combined Masters/PhD), or

The 5+1 internship program:a fifth year APAC accredited degree (i.e.Graduate Diploma of Professional Psychology), followed by a one year

Board-approved internship, or

The 4+2 internship program:a four year APAC-accredited degree,followed by a two year Board approved internship (4+2), or

The overseas qualifications pathway:qualifications that are assessed asequivalent to an APAC accredited six year sequence of study in psychology

and completion of a Board approved transitional program.

Note, each pathway is distinct and components from two or more pathways

cannot be combined to meet the supervised practice requirement for

general registration.

It is important that you refer to the Boards registration standards, codes and

guidelines before completing this application. These documents can be foundat www.psychologyboard.gov.au

This application will not be considered unless it is complete andall supporting documentation has been provided. All academictranscripts and evidence of university enrolment must beoriginal documents and must be sent directly to the AustralianHealth Practitioner Regulation Agency (AHPRA) by the issuingeducational institution. Supporting documentation mustbe certifiedin accordance with AHPRA guidelines. See Certifying documentsin

the Information and definitions section of this form.

Privacy and confidentialityThe Board and AHPRA are committed to protecting your personal information inaccordance with thePrivacy Act 1988 (Cth). The ways the Board and AHPRA may collect,

use and disclose your information are set out in the collection statement relevant to this

application, available at www.ahpra.gov.au/privacy .By signing this form, you confirm that you have read the collection statement. AHPRAsprivacy policy explains how you may access and seek correction of your personal

information held by AHPRA and the Board, how to complain to AHPRA about a breach of

your privacy and how your complaint will be dealt with. This policy can be accessed at

www.ahpra.gov.au/privacy .

Symbols in this form

Additional informationProvides specific information about a question or section of the form.

AttentionHighlights important information about the form.

Attach document(s) to this formProcessing cannot occur until all required documents are received.

Signature requiredRequests appropriate parties to sign the form where indicated.

Mail document(s) directly to AHPRARequires delivery of documents by an organisation or the applicant.

Completing this form Read and complete all questions.

Ensure that allpagesand required attachmentsare returned to AHPRA.

Use a blackor bluepen only.

Print clearly in B L O C K L E T TE R S

Place X in allapplicable boxes:

DO NOT send original documents unless specified

Do not use staples or glue, or affix sticky notes to your application.Please ensure all supporting documents are on A4 size paper.

SECTION A: Personal details

The information items in this section of the application marked with an asterisk (*) will appear on the public register.

1. What is your name and dateof birth?

If you have ever beenformally known by another

name, or you are providing

documents in another name,

you mustattach proof of yourname change unless this hasbeen previously provided to

the Board.

For more information, seeChange of namein the

Information and definitions

section of this form.

Title*

MR MRS MISS MS DR OTHER SPECIFY

Family name*

First given name*

Middle name(s)*

Previous names known by (e.g. maiden name)

Date of birth D D / M M / Y Y Y Y


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2. What are your birth andpersonal details?

Country of birth

City/Suburb/Town of birth

State/Territory of birth (if within Australia)

VIC NSW QLD SA WA NT TAS ACT

Sex*MALE FEMALE

Languages spoken other than English (optional)*

SECTION B: Proof of identity

You must provide proof of your identity with this application

The minimum requirements for overseas applicants, or those who have recently arrived in Australia, can be found in theAHPRA Proof of identity requirementsdocument under the heading What special circumstances apply to overseas applicantsor applicants who have recently arrived in Australia? This document is availableat www.ahpra.gov.au/identity

Youmust provide evidence from category A, B, and C.

You mustonly use each document once.

If your evidence from category C or B does not include your residential address, you mustalso provide evidence from category D.

Please indicate on the chart below which piece of evidence you are submitting for each category and attach the certified copies of

documents to your application.

3. Which documents from eachcategory will you provide forproof of identity?

The documents provided mustmeet the following criteria:

At least onedocument mustbein the applicants current name.

Your category B document musthave a recent photo.

All documents mustbe officiallytranslated into English.For documents translated inAustralia, the translator mustbe accredited by NAATI see www.naati.com.auFor documents translatedoverseas, see www.fit-ift.orgfor a list of authorities who providecertified translations. Please referto Translating documentsat

www.ahpra.gov.au/translateforfurther information.

Australian birth certificateextracts are notaccepted.

If using your passport, a certifiedcopy of the identity informationpage (the photo page) mustbe provided.

All documents mustbe truecertified copies of the original.See Certifying documentsin theInformation and definitionssectionof this form for more information.

Choose proof of identity documents to submit: (A document may only be used once for any category)

DocumentsCategory used:

DocumentsCategory used:

A B C A B C

Australian passport Medicare card NA NA

Overseas passport with current Aust. visa PAYG payment summary NA NA

Australian birth certificate NA Motor vehicle registration NA NA

Current Australian visa NA Financial institution statement NA NA

Australian Armed Services papers NA Taxation assessment notice NA NA

Travel documents with Aust. visa NA Health insurance card NA NA

Australian citizenship certificate NA Pension card NA NA

Australian driver licence NA Category D documents

Working with children check card NAA document from Category D is only required if your

Category B or C document does not provide evidence

of your residential address.

Firearm or shooters licence NA

Student ID card NA

International driver licence NA I have used a Category B or C document that

has my current residential addressProof of age card NA

Change of name certificate NA NA Mortgage papers

Australian marriage certificate NA NA Rate notices

Australian divorce papers NA NA Lease or tenancy agreement

Board registration certificate NA NA Utility account

Bank acct. details credit or ATM card NA NA Electoral enrolment card

You mustattach a certified copy of allproof of identity documents that you haveindicated above.


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SECTION C: Contact information

Once registered, you can change your contact information at any time. Please go to www.ahpra.gov.auand download and complete the change of address form CHDT-00 Request for change of address details on the register, or

log in to your AHPRA account to change your details online.

4. What are your contact details?Provide your current contact details below place an next to your preferred contact phone number.

Business hours

After hours

Mobile

Email

5. What is your residentialaddress?

When you are not yet

practising, or when you are

not practising the profession

predominantly at one address:

your residential address

will be recognised as

your principal place of

practice, and

the information items

marked with an asterisk (*)

will appear on the publicregister as your principal

place of practice.

Refer to the question belowfor the definition of principal

place of practice.

Residential address cannotbe a PO Box.

Site/building and/or position/department (if applicable)

Address(e.g. 123 JAMES AVENUE; or UNIT 1A, 30 JAMES STREET)

City/Suburb/Town*

State or territory(e.g. VIC, ACT)/International province* Postcode/ZIP*

Country (if other than Australia)

6. Will the address of yourprincipal place of practice bethe same as your residentialaddress?

Principal place of practice

for a registered health

practitioner is:

the address at which you

will predominantly practise

the profession; or

your principal place of

residence, if you are not

practising the professionor are not practising the

profession predominantly

at one address.

Principal place of practice

cannotbe a PO Box.

The information items marked

with an asterisk (*) will appear

on the public register.

YES NO Provide your Australian principal place of practice below


Address(e.g. 123 JAMES AVENUE; or UNIT 1A, 30 JAMES STREET)

City/Suburb/Town*

State/Territory*(e.g. VIC, ACT) Postcode*


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7. What is your mailing address?

Your mailing address is used

for postal correspondence.

My residential address

My principal place of practice

Other (Provide your mailing address below)


Address/PO Box(e.g. 123 JAMES AVENUE; or UNIT 1A, 30 JAMES STREET; or PO BOX 1234)

City/Suburb/Town

State or territory(e.g. VIC, ACT)/International province Postcode/ZIP

Country (if other than Australia)

SECTION D: Qualification for provisional registration

Registration as a provisional psychologistunder the 4+2 internship programpathway is dependent on the Board being satisfiedthat the applicant:

meets the mandatory registration standards

has completed an APAC-accredited four-year sequence of study (or its equivalent) in psychology in the past ten years at the time

of application, and has proposed a supervised practice program that is consistent with the Guidelines for 4+2 internship programs for provisional

psychologists and supervisors, which has been agreed by the applicant for provisional registration and the principal and

secondary supervisors.

Registration as a provisional psychologist under the 5+1 internship programpathway is dependent on the Board being satisfiedthat the applicant:


has completed an APAC-accredited four-year sequence of study (or its equivalent) in psychology in the past ten years at the time of

application, and

is currently enrolled in an APAC-accredited fifth year degree and evidence of enrolment is provided directly to AHPRA by the

educational institution.

Following completion of the fifth year degree continuation of provisional registration will be dependent on:

submission of evidence by the educational institution of successful completion of all components of the fifth year degree andeligibility to graduate, and

submission of a proposed supervision plan that is consistent with the Guidelines for the 5+1 internship program, which has been

agreed to by the provisional psychologist and the principal and secondary supervisors.

Registration as a provisional psychologist for applicants undertaking an APAC accredited higher degree leading to generalregistration is dependent on the Board being satisfied that the applicant:


has completed an APAC-accredited four-year sequence of study (or its equivalent) in psychology, and

is currently enrolled in an APAC-accredited higher degree and evidence of enrolment is provided directly to AHPRA by the

educational institution.

Registration as a provisional psychologistfor overseas trained applicants who hold qualifications equivalent to a six-year accreditedsequence of study in psychology in Australia is dependent on the Board being satisfied that the applicant:

meets the mandatory registration standards, and has proposed a supervised practice program that meets the requirements of the Transitional Program set out in the Policy for

overseas qualified applicants for registration.

Note:for applicants not currently residing in Australia the Board may consider granting provisional registration with conditions to enablea transition program to be arranged once the applicant arrives in Australia.


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8. What are the details ofyour qualificationsmeeting the provisionalregistration standard?

For more information, see

Certifying documentsin the



Most recent qualification and examinations/assessments

Title of qualification

Name of institution (University/College/Examining body)

Country

Start date Completion date

M M / Y Y Y Y M M / Y Y Y Y

Additional qualification and examinations/assessments

Title of qualification


Country

Start date Completion date

M M / Y Y Y Y M M / Y Y Y Y

You mustarrange to have the original transcript of your academic qualifications sent directlyto AHPRA by the issuing institution.

Attach a separate sheet if all your qualification details do not fit in the space provided.

9. Have you completed an

overseas qualification thatis substantially equivalent toa four-year APAC-accreditedsequence of study inpsychology in Australia?

YES NO All my qualifications listed above are accredited

Australian qualifications

You mustattach a certified copy of the assessment of your overseas qualifications from theAustralian assessing authority for overseas qualifications in psychology (the Australian

Psychological Society).

You may be required to submit additional information to assist with the Boards assessment of

your qualifications.

Note:this is in addition to your arranging for your transcripts to be sent directly to AHPRAby the issuing institution.

10. Are you applying to undertakea 4+2 internship program?

YES NO Go to the next question

Attachment required below then go to question 15

You mustattach:

a completed Supervised practice plan for provisional registration as a psychologist

(4+2 internship program) - SPPR-76

to provide detailed information about your planned program, and

a copy of your position description(s) relating to the proposed supervised

practice program. This must:

be on the letterhead of the organisation that is proposing to employ you for the

purposes of supervised practice, and

include at least a brief description of your work role, including duties, responsibilities

and reporting requirements, and hours of work, and be signed by an authorisedperson in the workplace.


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11. Are you applying to undertakea 5+1 internship program?


Provide details of your degree and attachments below then go to question 15

Title of qualification (degree)


You mustarrange for evidence of your current enrolment in an APAC-accredited fifth yearqualification (e.g. Graduate Diploma of Professional Psychology) to be sent directly to AHPRA

by the issuing institution.

Only the following forms of evidence will be accepted:

an official university or higher education institution document (transcript or letter from

Head of School) confirming your current enrolment, or

a print-out of your enrolment record (only if your Head of School has separately sent

AHPRA a list of enrolled students confirming your enrolment).

A letter of offer does not constitute evidence of enrolment.

You should also note that, following completion of the Graduate Diploma of Professional

Psychology, you will be required to submit the following before progressing to the internship

year of the 5+1 program:

evidence of successful completion of all the requirements of the degree and eligibility

to graduate,

a completed Internship program plan (5+1 internship) - INPP-76to provide detailed

information about your planned internship program, and

a copy of your position description(s) relating to the proposed supervised practice

program.

12. Are you applying to undertakean APAC-accredited higherdegree at fifth and sixthyear leading to general

registration?


Provide details of your degree and attachments below then go to question 15

Title of qualification (degree)


You mustarrange for evidence of your current enrolment to be sent directly to AHPRA by theissuing institution. Only the following forms of evidence will be accepted:

an official university or higher education institution document (transcript or letter from

Head of School) confirming your current enrolment, or

a print-out of your enrolment record (only if your Head of School has separately sent us a

list of enrolled students confirming your enrolment).

A letter of offer does not constitute evidence of enrolment.

13. Are you applying to undertakea three month TransitionalProgram as required by the

Policy for overseas qualified

applicants for registration?

YESYoumustattach formAATP-76 Application for approval of a transitional programto provide detail of your proposed Transitional Program. This must:

be signed by your proposed supervisor, and

attach a copy of the position description/s for the proposed supervised practice

work role(s).

If you are not currently residing in Australia, the Board may consider an application

withoutAATP-76 - Application for approval of a transitional program. In such cases,

the Board may propose to grant you provisional registration with a condition that you

do not practise in Australia until form AATP-76 is provided and approved by the

Board. If this condition is not met within 12 months of your registration beingapproved, your provisional registration may not be renewed.

NOYou must choose your pathway.You must answer YES to one of questions 10, 11,12 and 13.


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14. Have you undertakenpsychological practice in thelast five years?

The Boards Recency of practice registration standardrequires that applicants have recent psychological

practice experience within the last five years. Refer to the Information and definitions section of this form and the

Recency of practice registration standard in the Standards and guidelinessection of the website.

YESYoumustattach your signed and dated curriculum vitae outlining your practicehistory.

NO You may be required to undertake other remedial action to meet the Boards recency of practice

standard refer to the Recency of practice registration standardand the Policy for recency of

practice requirementsin the Standards and guidelinessection of the website.

SECTION E: Registration history

15. What is your healthpractitioner registrationhistory?

Registration history only

applies if you are currently,

or have been previously,

registered as a health

practitioner.

If you have been registered

outside of Australia, the

Board requires a Certificateof Registration Status or

Certificate of Good Standing

from everyjurisdiction outsideof Australia in which you are

currently, or have previouslybeen registered as a health

practitioner during the pastfive years.

Most recent registrationState/Territory/Country

Profession

Period of registration

D D / M M / Y Y Y Y to

D D / M M / Y Y Y Y

Additional registrationState/Territory/Country

Profession

Period of registration

D D / M M / Y Y Y Y to D D / M M / Y Y Y Y

If you have been registered outside of Australia, you mustarrange for original Certificates ofRegistration Status or Certificates of Good Standing to be forwarded directly from the registration

authority to your AHPRA state office.

Refer to www.ahpra.gov.au/About-AHPRA/Contact-Usfor your AHPRA state office address.

Attach a separate sheet if all your registration history does not fit in the space provided.

SECTION F: Suitability statements

Information required by the Board to assess your suitability for registration is detailed in the following questions. It is recommended

that you provide as much information as possible to enable the Board to reach a timely and informed decision.

Please note that registration is dependent on suitability as defined in the National Law, and the requirements set out in the Boards

registration standards. Refer to www.psychologyboard.gov.au/Registration-Standardsfor further information.

16. Do you have any criminalhistory in Australia?

It is important that you have a clear understanding of the definition of criminal history. For more information, see

Criminal historyin the Information and definitionssection of this form.

YES NO

Provide a separate sheet with details of your criminal history in Australia and explanation

of circumstances.

17. Do you have any criminalhistory in another country?

For more information,see Criminal historyin theInformation and definitions


YES NO

Provide a separate sheet with details of your criminal history in another country and explanation

of circumstances.

18. Have you previously beenregistered to practise as apsychologist in Australia?

If you have previously been registered to practise as a psychologist in Australia you have met the requirementsof the Boards English language skills registration standard. However, the Board may still require you to provideevidence of your English language skills. In such a case, the Board will contact you.

YES Go to question 22 NO Go to the next question


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19. Did you undertake andcomplete your secondaryeducation and your tertiaryqualifications in theprofession, in English, in oneof the countries listed?

For more information, seeEnglish language skillsin theInformation and definitionssection of this form.

Australia Canada New Zealand Republic of Ireland South Africa United Kingdom United States of America


Attachment required below then go to question 22

You mustsubmit a certified copy of the original evidence of having undertaken yoursecondary education in English.

20. Please provide the testreport form number foryour International EnglishLanguage Test System (IELTS) Academic moduleexamination.

Pass result mustbe obtainedin one sitting.

International English Language Test System (IELTS) Academic moduleTest report form number:

The Board requires an IELTS Academic module score of at least 7 in each of the four components

(listening, reading, writing and speaking).

You mustsend a certified copy of your Board-approved English language test results to yourAHPRA state office. AHPRA will verify your test results directly with the testing authority (forexample, by secure internet login).

21. Have your results from the

above mentioned Englishlanguage examinationbeen obtained within twoyears prior to applying forregistration?

YES NO

You mustattach evidence that you have actively maintained employment as a registered healthpractitioner using English as the primary language of practice in one of the following countries:

Australia

Canada

New Zealand

Republic of Ireland

South Africa

United Kingdom

United States of America

Applicants who have not achieved their results within two years prior to applying for registration

or are unable to provide evidence of actively maintaining employment using English as the

primary language in one of the countries listed above are ineligible for registration.

22. Do you commit to havingappropriate professional

indemnity insurancearrangements in place forall practice undertaken duringthe registration period?

The Board requires all applicants for provisional registration to have appropriate professional indemnity

arrangements in place when practising. Applicants unable to meet this requirement are ineligible for registration.

For more information, see Professional indemnity insurancein the Information and definitionssection of this form.

YES NO

23. Do you have an impairmentthat detrimentally affects,or is likely to detrimentallyaffect, your capacity topractise the profession?

For more information, see Impairmentin the Information and definitionssection of this form.

YES NO

You mustattach to this application details of any impairments and how they are managed.

24. Is your registration inany profession currentlysuspended or cancelled inAustralia (under the NationalLaw or a corresponding priorAct) or overseas?

YES NO

You mustattach to this application details of any registration suspension or cancellation.

25. Have you previously had yourregistration cancelled, refusedor suspended in Australia(under the National Law or acorresponding prior Act) oroverseas?

YES NO

You mustattach to this application details of any cancellation or refusal.


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26. Has your registration everbeen subject to conditions,undertakings or limitations inAustralia (under the NationalLaw or a corresponding priorAct) or overseas?

YES NO

You mustattach to this application details of any conditions, undertakings or limitations.

27. Are you disqualified fromapplying for registration,or being registered, in anyprofession in Australia(under the National Law,a corresponding prior Actor a law of a co-regulatoryjurisdiction), or overseas?

Co-regulatory jurisdictionmeans a participating jurisdiction (of the National Law) in which the Act applying (theNational Law) declares that the jurisdiction is not participating in the health, performance and conduct processprovided by Divisions 3 to 12 of Part 8 (of the National Law).

YES NO

You mustattach to this application details of any disqualifications.

28. Have you been, or are youcurrently, the subject ofconduct, performance orhealth proceedings whilstregistered under the NationalLaw, a corresponding prior

Act, or the law of anotherjurisdiction in Australiaor overseas, where thoseproceedings were notfinalised?

YES NO

You mustattach to this application details of any conduct, performance or health proceedings.

SECTION G: Obligations and consent

Before you sign and date this form, make sure that you have answered all of the relevant questions correctly and read the statements below.An incomplete form may delay processing and you may be asked to complete a new form. For more information, see theInformation and definitionssection of this form.

Obligations of registered health practitionersThe National Law pt 7 div 11 sub-div 3 establishes the legislative obligations ofregistered health practitioners. A contravention of these obligations, as detailed at points

1, 2, 4, 5, 6 or 8 below does not constitute an offence but may constitute behaviour for

which health, conduct or performance action may be taken by the Board. Registeredhealth practitioners are also obligated to meet the requirements of their Board as

established in registration standards, codes and guidelines.

Continuing professional development1. A registered health practitioner must undertake the continuing professional

development required by an approved registration standard for the health profession

in which the practitioner is registered.

Professional indemnity insurance arrangements2. A registered health practitioner must not practise the health profession in which

the practitioner is registered unless appropriate professional indemnity insurance

arrangements are in force in relation to the practitioners practice of the profession.3. A National Board may, at any time by written notice, require a registered health

practitioner registered by the Board to give the Board evidence of the appropriateprofessional indemnity insurance arrangements that are in force in relation to thepractitioners practice of the profession.

4. A registered health practitioner must not, without reasonable excuse, fail to comply

with a written notice given to the practitioner under point 3 above.

Notice of certain events5. A registered health practitioner must, within 7 days after becoming aware that a

relevant eventhas occurred in relation to the practitioner, give the National Board

that registered the practitioner written notice of the event. Relevant eventmeansa) the practitioner is charged, whether in a participating jurisdiction or elsewhere,

with an offence punishable by 12 months imprisonment or more; or

b) the practitioner is convicted of or the subject of a finding of guilt for an

offence, whether in a participating jurisdiction or elsewhere, punishable byimprisonment; or

c) appropriate professional indemnity insurance arrangements are no longer in

place in relation to the practitioners practice of the profession; ord) the practitioners right to practise at a hospital or another facility at which health

services are provided is withdrawn or restricted because of the practitioners

conduct, professional performance or health; or

e) the practitioners billing privileges are withdrawn or restricted under the Human

Services (Medicare) Act 1973(Cth) because of the practitioners conduct,

professional performance or health; orf) the practitioners authority under a law of a State or Territory to administer,

obtain, possess, prescribe, sell, supply or use a scheduled medicine or class of

scheduled medicines is cancelled or restricted; org) a complaint is made about the practitioner to the following entities

(i) the chief executive officer under the Human Services (Medicare) Act 1973

(Cth);

(ii) an entity performing functions under the Health Insurance Act 1973 (Cth);(iii) the Secretary within the meaning of the National Health Act 1953 (Cth);

(iv) the Secretary to the Department in which the Migration Act 1958(Cth) is

administered;

(v) another Commonwealth, State or Territory entity having functions relatingto professional services provided by health practitioners or the regulation of

health practitioners.

h) the practitioners registration under the law of another country that provides

for the registration of health practitioners is suspended or cancelled or madesubject to a condition or another restriction.

Change in principal place of practice, address or name6. A registered health practitioner must, within 30 days of any of the following changes

happening, give the National Board that registered the practitioner written notice of

the change and any evidence providing proof of the change required by the Board

a) a change in the practitioners principal place of practice;b) a change in the address provided by the registered health practitioner as the

address the Board should use in corresponding with the practitioner;

c) a change in the practitioners name.

Employers details7. A National Board may, at any time by written notice given to a health practitioner

registered by the Board, ask the practitioner to give the Board the followinginformation

a) information about whether the practitioner is employed by another entity;

b) if the practitioner is employed by another entity

(i) the name of the practitioners employer; and(ii) the address and other contact details of the practitioners employer.

8. The registered health practitioner must not, without reasonable excuse, fail to

comply with the notice.


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Credit/Debit card payment slip please fill out

Amount payable

$

Visa or MasterCard number

Expiry date

M M / Y Y

Name on card

Cardholders signature

SIGN HERE

ConsentI consent to the Board and AHPRA making enquiries of, and exchanging information with,the authorities of any Australian state or territory, or other country, regarding my practice

as a health practitioner or otherwise regarding matters relevant to this application.

I authorise the Board to obtain my criminal history in Australia and overseas.

I understand that: a complete criminal history, including resolved and unresolved charges, spent

convictions, and findings of guilt for which no conviction was recorded,

will be released to the Board, and

information will be extracted from this form and used for the purpose of criminalhistory checking. This information may be used by Australian police services for

law enforcement purposes including the investigation of any outstanding criminaloffences.

I acknowledge that: the Board may validate documents provided in support of this application as

evidence of my identity, and

failure to complete all relevant sections of this application and to enclose allsupporting documentation may result in this application not being accepted.

I undertake to comply with all relevant legislation and Board registration standards,

codes and guidelines.

I confirm that I have read the privacy and confidentiality statement for this form.

I declare that:

the above statements, and the documents provided in support of this application,

are true and correct, and I am the person named in the attached documents.

I make this declaration in the knowledge that a false statement is grounds for the Board

to refuse registration.I am aware that personal information that I provide may be given to a third party for

regulatory purposes, consistent with the National Law.

Signature of applicant

SIGN HEREName of applicant

Date

D D / M M / Y Y Y Y

SECTION H: Payment

You are required to pay a registration fee.

Your required payment is detailed below:Use the table below to select your registration fee. Your registration fee depends on your principal place of practice, as applicants whose principal

place of practice is New South Wales are entitled to a rebate from the NSW Government.

Registration fee: Amount payable:

$ INSERT FEE = $ INSERT FEERegistration fee $431 Applicants mustpay 100% of the stated fees

at the time of submitting the application.Registration fee for NSW registrants $330

Registration period The annual registration period for provisional psychologists is 12 months.

If your application is approved you will be registered for 12 months from the date of approval. Refund rules The registration fee will be refunded if the application is not approved.

29. How are you paying your fees?

Payment by cheque, moneyorder or bank draft must be in

Australian currency, drawn on

an Australian bank.

A receipt will be posted.

Mark one box below only

Visa or MasterCard Cash/EFTPOS Complete credit/debit card payment slip below (only available if paying in person)

Cheque/Money order/Bank draft

You mustattach cheque or money order payable to the Australian Health Practitioner

Regulation Agency.

On the back of the cheque, money order or bank draft, you mustwrite: your name your date of birth, and your registration number (if applicable).


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SECTION I: Checklist

Have the following items been attached or arranged, if required?

Additional documentation Attached

Question 1 Evidence of a change of name

Question 3 Certified copies of all documents that provide sufficient evidence of your identity

Question 8 Original academic transcripts for allyour relevant qualifications must be sent directly to AHPRA by the issuing institution

Question 9 Assessment of your qualifications that is completed by the Board-approved assessment body

Question 10 A completed Supervised practice plan (4+2 internship)form

Question 10 A copy of your position description(s)

Question 11 Evidence of your current enrolment in an APAC-accredited Graduate Diploma of Professional Psychology requested from

relevant authority

Question 12 Evidence of current enrolment requested from relevant authority

Question 13 FormAATP-76 Application for approval of a transitional program

Question 14 Signed and dated curriculum vitae outlining your practice history

Question 15 Certificate of Registration Status or Certificate of Good Standing has been requested from relevant authority

Question 15 A separate sheet with additional registration details

Question 16 A separate sheet with an explanation of circumstances of your criminal history in Australia

Question 17 A separate sheet with an explanation of circumstances of your criminal history overseas

Question 19 A certified copy of the original evidence of having undertaken your secondary education and tertiary qualifications in English

Question 20 Evidence of the successful completion of an approved English language test has been requested from relevant authority

Question 21 Evidence that you have actively maintained employment using English as the primary language of practice

Question 23 A separate sheet with your impairment details

Question 24 A separate sheet with your current suspension or cancellation details

Question 25 A separate sheet with you previous suspension, cancellation, or refusal details

Question 26 A separate sheet with your conditions, undertakings, or limitations details

Question 27 A separate sheet with your disqualification details

Question 28 A separate sheet with your conduct, performance or health proceedings

Payment

Registration fee

If paying by cheque/money order/bank draft, your name and registration number are written on the back

Please post this form withpayment and requiredattachments to:

AHPRAGPO Box 9958IN YOUR CAPITAL CITY (refer below)

You may contact AHPRA on

1300 419 495 or you can lodge an enquiry

at www.ahpra.gov.au

Sydney NSW 2001 Canberra ACT 2601 Melbourne VIC 3001 Brisbane QLD 4001

Adelaide SA 5001 Perth WA 6001 Hobart TAS 7001 Darwin NT 0801


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*APRO-7612*APRO-76


CERTIFYING DOCUMENTSDO NOT send original documents unless specified.Copies of documents provided in support of an application, or other purposerequired by the National Law, must be certified as true copies of the originaldocuments. Each and every certified document must:

be in English. If original documents are not in English, you must provide acertified copy of the original document and translation in accordance withAHPRA guidelines, which are available at

www.ahpra.gov.au/registration/registration-process be initialled on every page by the authorised officer. For a list of people

authorised to certify documents, visit www.ahpra.gov.au/certify

be annotated on the last page as appropriate e.g. I have sighted theoriginal document and certify this to be a true copy of the original andsigned by the authorised officer, and

list the name, date of certification, and contact phone number, andposition number (if relevant) and have the stamp or seal of the authorisedofficer (if relevant) applied.

Certified copies will only be accepted in hard copy by mail or in person (notby fax, email, etc). Photocopies of previously certified documents will not beaccepted. For more information, AHPRAs guidelines for certifying documentscan be found online at www.ahpra.gov.au/certify

CHANGE OF NAMEYou must provide evidence of a change of name if you have ever been formallyknown by another name(s) or any of the documentation you are providing insupport of your application is in another name(s).

Evidence must be a certified copy of one of the following documents:

Standard marriage certificate (ceremonial certificates will not be accepted).

Deed poll.

Change of name certificate.

Faxed, scanned or emailed copies of certified documents will not be accepted.

CRIMINAL HISTORYCriminal history includes the following, whether in Australia or overseas,at any time:

every conviction of a person for an offence every plea of guilty or finding of guilt by a court of the person for an

offence, whether or not a conviction is recorded for the offence, and

every charge made against the person for an offence.

Under the National Law, spent convictions legislation does not applyto criminal history disclosure requirements. Therefore, you must disclose yourcomplete criminal history as detailed above, irrespective of the time that haslapsed since the charge was laid or the finding of guilt was made.

The Board will decide whether a health practitioners criminal historyis relevant to the practice of the profession.

Do not provide copies of a criminal history check. AHPRA will conduct a checkon your behalf. For more information, view the full registration standard onlineat www.psychologyboard.gov.au/Registration-Standards

ENGLISH LANGUAGE SKILLSTo be eligible for registration you mustbe able to provide evidenceof English language skills that meet the Boards English language skillsregistration standardwhich can be found atwww.psychologyboard.gov.au/Registration-Standards

IMPAIRMENTImpairment means a physical or mental impairment, disability, condition,or disorder (including substance abuse or dependence) that detrimentallyaffects or is likely to detrimentally affect your capacity to practisethe profession.

The National Law requires you to declare any impairments at the time ofapplication. If you have an impairment, you will need to provide details of theimpairment and how it is managed.

PRACTICEPractice means any role, whether remunerated or not, in which you use yourskills and knowledge as a health practitioner in your profession. Practice isnot restricted to the provision of direct clinical care. It also includes usingprofessional knowledge in a direct non-clinical relationship with clients,working in management, administration, education, research, advisory,regulatory or policy development roles, and any other roles that impacton safe, effective delivery of services in the profession.

PROFESSIONAL INDEMNITY INSURANCE (PII)You must have PII, or some alternative form of indemnity cover that complieswith the Boards standard, for all aspects of your practice. Initial registrationand annual renewal of registration requires a declaration that you will becovered for all aspects of practice for the whole period of the registration.You may be covered by your Australian employers PII - you will need toconfirm this with your employer.

For more information, view the complete registration standard online at

www.psychologyboard.gov.au/Registration-Standards

RECENCY OF PRACTICEIn accordance with the Recency of practice registration standardan individualmust, at the time the application for renewal of registration is made, be able

to demonstrate that he or she has practised unconditionally as a registeredpsychologist in the past five years.

Individuals who are currently enrolled in or have successfully completeda Board-approved sequence of study required for registration within theprevious five years are exempt. Practitioners who do not meet the recencyof practice requirements may be required to undertake remedial action inorder to be eligible to renew their registration.

Additional guidance on remedial action to meet recency of practicerequirements is included in the Policy for recency of practice requirements.

For more information, view the Recency of practice registration standardandthe Policy for recency of practice requirementsonline atwww.psychologyboard.gov.au/Standards-and-Guidelines