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ASGR-40

*ASGR-40*

SECTION B: Personal details

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

6. What is your name?

If you have ever been formally known by another name, or you are providing documents in another name, you must attach proof of your name change unless this has been previously provided to the Board.

Title* MR MRS Family name*

First given name*

MISS

MS

DR

OTHER

SPECIFY

For more information see Change of name in the Information and definitions section of this form.

Middle name(s)*

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

7. What are your birth and personal details?

Date of birth

D D / MM / Y Y Y Y

Country of birth

City 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 C: Contact information

Once registered, you can change your contact information at any time. Please go to www.ahpra.gov.au and

  • 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.

8. What is your residential address?

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

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

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

  • the information items marked * will appear on the public register as your principal place of practice.

Refer to the next question for the definition of principal place of practice.

City/Suburb/Town*

Residential address cannot be a PO Box.

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

Postcode/ZIP*

Country (if other than Australia)

Effective from: 9 September 2014

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