APPLICATION TO BE ASSESSED FOR RECOGNITION AS A SPECIALIST

To be eligible to apply for specialist assessment, you are required to have completed and satisfied all training and
examination requirements and hold a specialist qualification from overseas that allows you to practise in your
field of speciality in your country of training.

Lodge this form with the specified supporting documents.

Before completing your application, please read the below information:

 Please ensure that you have read the IMG Assessment Policy (Australia)
 Once a complete application is received, RANZCR will forward an invoice for payment. An assessment will not
be confirmed until the assessment fee has been received.
 RANZCR recommends you read available information on the MBA (www.medicalboard.gov.au) and RANZCR
(www.ranzcr.com) websites before completing the application forms.
 For correct witnessing procedures please refer to the MBA website (www.medicalboard.gov.au)

CHECKLIST OF THE DOCUMENTATION TO BE SUBMITTED WITH THIS APPLICATION:

☐ Completed Application to be Assessed for Recognition as a Specialist
☐ Curriculum Vitae (in College specific format)
☐ Primary and Specialist qualification(s) –copies, in original language and English translations. RANZCR is able
to accept copy of translations used for EPIC primary source verification process.
☐ Certificates of Fellowship of specialist medical organisations/institutions
☐ Certificate(s) of Good Standing – must cover the last two years of practice and be dated within six months of
the application. To be sent directly to RANZCR from issuing authority.
☐ Certificate of specialist registration status
☐ Evidence of English Language Proficiency (please see: www.medicalboard.gov.au )
☐ Confirmation of identity
☐ EPIC identification form (including a certified copy of your passport OR
☐ Certified copy of details page of passport including signature, details and photograph
☐ Statutory declaration or certified copy of evidence of change of name (if applicable)
☐ Evidence of participation in a continuing professional development program. Eg: annual or triennium CPD
certificate confirming CPD requirements have been met. DO NOT send individual certificates.
☐ If you wish to allow the College to liaise with a third party regarding your application, please complete and
submit the release of information form.

Additional documents required for applicants also applying for area of need assessment:
☐ Completed Area of Need application
☐ AON declaration for all intended work sites. The AoN is issued by the health department in the state or
territory in which the position(s) is located.
☐ Position description
☐ Log book (covering the last 2 years if Tier B interventional procedures are required in the AoN position)

LODGEMENT OF APPLICATION
The completed application to be submitted electronically to [email protected] Please submit in one email with
three attachments:
Attachment 1: application form
Attachment 2: CV
Attachment 3: all supporting documentation

Specialist assessment pathway – application form (v 3.2)

© The Royal Australian and New Zealand College of Radiologists®
July 2018 Page 1 of 7
STATUTORY DECLARATIONS
The following are accepted as eligible to witness declarations and required assessment documentation:
 For correct witnessing procedures please refer to the MBA website (www.medicalboard.gov.au)

IN AUSTRALIA OVERSEAS
 A Justice of the Peace  Notary Public
 Chief Magistrate – Police Magistrate – Resident  Commissioner of Oaths (South Africa, Sudan and Canada
Magistrate – Special Magistrate. only)
 A person appointed under the Statutory  A person appointed to hold, or act in, the office in a
Declarations Act 1959, as amended, or under a country or place outside Australia in an Australian Embassy,
State Act to be a Commissioner for Declarations. High Commission, Legation or other post as:
 A Notary Public. o Australian Consul-General, Consul or Vice-
 A person appointed as a Commissioner for Consul.
Declarations u nder the Statutory Declarations Act o Australian Trade Commissioner or
1911, or under that Act as amended, and holding Consular Agent.
office immediately before the commencement of o Australian Ambassador or High
the Statutory Declarations Act 1959. Commissioner.
o Australian Minister, Head of Mission,
Commissioner, Chargé d’Affaires or Counsellor.
o Australian Secretary or Attaché.
Note: A Justice of the Peace registered outside Australia is
NOT accepted for witnessing documentation.
It is important that the witness state in their wording that it is a ‘certified true copy’. A sample of acceptable
wording is shown below.

The name and title of the witness and the date certified must also be included in the certification. Certification
should be made on each page of the actual document. If the witness certifies the document on a separate page,
it needs to be correctly notary bound (no staples allowed).

EVIDENCE OF ENGLISH LANGUAGE PROFICIENCY

You must supply evidence of English language proficiency. Please see the English Language Skills Registration
Standard of the Medical Board of Australia: MBA English Language Standards Results must be from the 2 years
immediately prior to application.

VERIFICATION OF QUALIFICATIONS
ECFMG and EPIC
The primary source verification of medical qualifications is mandated under the Health Practitioner Regulation
National Law Act 2009 (National Law) for all IMGs seeking registration in any category in Australia.
IMGs are required to submit medical qualifications directly to ECFMG’s Electronic Portfolio of International
Credentials (EPIC) for verification, but also complete an AMC online application to establish an AMC portfolio. The
EPIC verification outcome status and EPIC report will be uploaded to the AMC’s qualifications portal once received
from ECFMG. This portal is used by the Medical Board of Australia for registration purposes, and by Australian
specialist medical colleges for assessment purposes.

PRIVACY
Your privacy is respected by the College. Information collected by the College may be used for administering
the assessment of overseas trained specialists and provided to officers of the College involved in specialist
assessment, the respective employer, supervisors, the Australian Medical Council and the Medical Board of
Australia. If you have any privacy concerns or would like to verify information held about you, please
contact the College. Please refer to the College’s Privacy policy at: www.ranzcr.com
APPLICATION TO BE ASSESSED FOR RECOGNITION AS A SPECIALIST
Please ensure that all sections of this form are completed prior to lodgement with the College.

APPLICATION/ASSESSMENT TYPE
Specialist Recognition ☐
Dual (AON & Specialist) ☐
Area of Need only ☐

AREA OF MEDICAL PRACTICE FOR WHICH ASSESSMENT IS SOUGHT

Field(s) of specialisation for which assessment is sought for practice in Australia
Diagnostic Radiology ☐ Radiation Oncology ☐

APPLICANT DETAILS
Family name

Given names

Date of birth
DD/MM/YYYY Male☐ Female ☐

Country of birth

Address

State
Postcode
Country

Home phone
Work phone

Mobile
Email address

Alternate email

NAME CHANGE/VARIATION
Is the name shown above the same as that shown on all the attached documents?
☐Yes ☐No
* If NO, you are required to attach certified documentary evidence of your change of name. If submitting a statutory
declaration, ensure that all variations are explained and state which name you wish to be known for specialist
assessment purposes.

EPIC Number AMC Number

Head Office: Level 9, 51 Druitt Street, Sydney NSW 2000, Australia Ph: +61 2 9268 9777 Email: [email protected]
New Zealand Office: Floor 6, 142 Lambton Quay, Wellington 6011, New Zealand Ph: +64 4 472 6470 Email: [email protected]
Web: www.ranzcr.com ABN 37 000 029 863
Page 3 of 7
PRIMARY MEDICAL QUALIFICATION

Country of training Year qualified

Primary qualification Year awarded
Name on qualification
Medical school
Issuing university
Duration of training ☐2 ☐3 ☐4 ☐5 ☐6+
INTERN TRAINING QUALIFICATIONS (If insufficient space, please provide information required in an attachment)
Institution
From (date) DD/MM/YYYY To (date) DD/MM/YYYY
Rotations covered

PRINCIPAL/HIGHEST SPECIALIST MEDICAL QUALIFICATION

If you have not already done so, you must submit an application to the Australian Medical Council for Primary Source Verification of
this qualification.

Specialist qualification Year qualified

Country of training Year awarded
Institution awarding
qualification (medical college)
Issuing university (if
applicable)
Field of specialty
Duration of training ☐2 ☐3 ☐4 ☐5 ☐6+
(Further details may be provided in the curriculum vitae)

Training site accredited by

SPECIALIST EXAMINATIONS
Institution
Date DD/MM/YYYY
Speciality/subspecialty

Components of exam

Examination regulatory
body:
SECONDARY/SUPPORTING SPECIALIST MEDICAL QUALIFICATION
Qualification Year qualified
Country of training Year awarded
Institution awarding
qualification (medical college)
Issuing university
Duration of training (in years) ☐2 ☐3 ☐4 ☐5 ☐6+
(Further details may be provided in the curriculum vitae)

Training site accredited by

Examination regulatory
body:
ADDITIONAL QUALIFICATION

Qualification Year qualified

Country of training Year awarded

Institution awarding Issuing university
qualification
Duration of training (in years) ☐2 ☐3 ☐4 ☐5 ☐6+
(Further details may be provided in the curriculum vitae)

RESTRICTIONS ON PRACTICE
Are you or have you been subject to any restrictions or limitation under any law or regulation?
☐Yes ☐No If ‘YES’, please supply details

Have you been charged or convicted of a criminal offense (other than minor traffic or other trivial offenses)?
Yes No If ‘YES’, please supply details

DECLARATION BY APPLICANT
Please print/ type clearly in sections below and complete all fields
I, (Name)
of (Address)

DO SOLEMNY AND SINCERELY DECLARE THAT:

 I am the person identified in the Application to be Assessed for Recognition as a Specialist.
 I am the person who has signed below.
 I have familiarised myself with the requirements, procedures and policies as set out in relevant MBA and
College publications.
 The statements made, and the information provided, in this application form and in the identified documents
attached are true and complete.
 I consent to the College collecting information

Signature:

Date:

SUBMIT YOUR COMPLETED APPLICATION and ACCOMPANYING DOCUMENTS ELECTRONICALLY TO THE

COLLEGE at [email protected] as per the instructions on the front page:
The completed application to be submitted electronically to [email protected] Please submit in one email
with three attachments:
Attachment 1: application form
Head Office:
Attachment 2: CVLevel 9, 51 Druitt Street, Sydney NSW 2000, Australia Ph: +61 2 9268 9777 Email: [email protected]
New Zealand Office: Floor 6, 142 Lambton Quay, Wellington 6011, New Zealand Ph: +64 4 472 6470 Email: [email protected]
Web: www.ranzcr.com ABN 37 000 029 863
Page 5 of 7
 Attachment 3: all supporting documentation

AUTHORITY TO RECEIVE INFORMATION ABOUT AN APPLICANT

Under the Privacy Act 1988 (Cth), the College is generally not permitted to disclose personal information about a
College candidate/applicant to a third party (e.g. a relative, friend or agent) without the consent of the
candidate/applicant. A candidate/applicant may authorise a third party (agent) to communicate and/or act on
their behalf by completing the following details.

Candidate/Applicant authorisation (Please print clearly)

I, (full name)

Date of birth: DD/MM/YYYY

Address:

authorise my agent to (Please tick appropriate box/es):

Communicate with the College by telephone, email or written correspondence on my behalf regarding the
processing and progress of my application.
Communicate with the College on my behalf regarding the results of relevant assessments.
Undertake any other action reasonably necessary for the processing of my application on my behalf, except
withdrawal forms/letters (they must be completed by the candidate/applicant).

DD/MM/YYYY
Candidate/Applicant’s signature Date

Agent’s consent (Please print clearly)

I, (full name)

consent to act as agent of (candidate/applicant’s name)

as authorised above.

My contact details are:

Company:
Address:

Business phone: Mobile phone:

Email address:

Your privacy is respected by the College. Information collected by the College may be used for administering the
assessment of overseas trained specialists and provided to officers of the College involved in specialist
assessment, the respective employer, supervisors, the Australian Medical Council and the Medical Board of
Australia.

Head
Head
Office:
Office:Level
Level
9, 9,
5151
Druitt
Druitt
Street,
Street,
Sydney
Sydney
NSWNSW2000,
2000,
Australia
AustraliaPh:Ph:
+61+61
2 9268
2 9268
9777
9777Email:
Email:
[email protected]
[email protected]
New
New
Zealand
Zealand
Office:
Office:
Floor
Floor
6, 6,
142142
Lambton
Lambton Quay,
Quay,Wellington
Wellington
6011,
6011,
New
NewZealand
ZealandPh:Ph:
+64+64
4 472
4 472
6470
6470Email:
Email:
[email protected]
[email protected]
Web:
Web:www.ranzcr.com
www.ranzcr.comABNABN3737000000
029029
863
863