Rural Clinical Elective Application Form

Submission Time Frames

Important Notice for Elective Placement Period

Period	Submission Commencement	Submission Deadline	Review Period
July/August 2020	01-Nov-19	31-Dec-19	January 2020
December 2020/January 2021	01-Feb-20	30-Apr-20	July 2020
test	02-Jun-18	02-Jun-20	1

Please note that we will not assess applications received outside of the above timeframes.

Personal Details

Family Name:

Title:

Given Name:

Preferred Name:

Correspondence Address:

Home Address (if different from Correspondence Address):

Country:

Telephone: Please ensure you prefix the number with your country code.

Email Address:

Nationality:

Passport Number:

Date of Birth:

Gender:

Emergency Contact Name:

Emergency Contact Telephone:

Emergency Contact Address:

Emergency Contact Relationship:

Have you received notification of a confirmed two week RFDS placement?

Please list your three preferred location/hospital in order (the maximum period is four weeks). Please note placements are ONLY during the periods July/August OR December/January. Placement requests outside these periods WILL NOT be considered.

Total number of elective weeks (the maximum period is four weeks):

Please state in 200 words or less why you have chosen particular rural sites for your elective.

Please specify your three preferred elective dates:

Elective from:

To:

Elective from:

To:

Elective from:

To:

Have you contacted any department/s, if so, who/where?

Academic

Current University/Medical School Name:

Course Contact Name:

Course Contact Email:

Present Year of Study:

Year of Graduation:

Month of Graduation:

Fees

Students who are offered a placement will be charged a non-refundable placement fee which is paid online once details are confirmed:

International medical students: $1,000.00
Australian and NZ medical students: $220.00
UWA & Notre Dame Fremantle medical students: No fee

Student’s Knowledge of English

Documents

Documents required to be uploaded when submitting this Application:

A copy of the identification pages of your passport endorsed by your Faculty representative (not applicable for UWA or Notre Dame Fremantle medical students);
Proof of proficiency in written and spoken English — if not your first language, or your course is not taught in English, IELTS or TOEFL or a statement from your university. You must be able to understand, write and speak English competently;
A letter from your Faculty confirming your student status and level and in good standing;
Your current CV;
Any additional documentation you deem appropriate to submit.

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Submission

By submitting this form, you:

agree that the specified fees are non-refundable; and
have supplied the correct information in the form; and
attached the required identity and eligibility documentation.

I agree with the specified terms of submission.