Application for Skills Assessment Please read the accompanying explanatory notes on pages 6 8 before completing this form. All pages of every requested document must be provided and you must sign the declarations on page 10 11. If you require more space to answer questions attach a signed and dated sheet giving the necessary details. All applications are considered on a case by case basis. Note: This is not an application to sit an assessment / examination Attach 2 recent passport photographs here. Sign and date the back of each photograph. Your Personal Details 1 Title Mr Ms 2 First name 3 Middle name/s 4 Last name 5 Other names (eg. maiden name) 6 Gender Male Female 7 Birth Country 8 Date of Birth (dd/mm/yyyy) 9 Country of permanent residence 10 Contact address 11 Home phone number 12 Fax number 13 Work phone number 14 Email address Agent Details Only enter information in these fields if you are using an agent. Note that an Agent Authorisation Form must accompany this application when an agent is used. This form may be found on the APC website. 15 Agent s name 16 Agent s address 1
Application Type Please indicate which stream you wish to be considered for. Do not tick Stream A or Stream B if you are a graduate from an Australian or New Zealand pharmacy program. 17 Stream A Stream B 18 It is my intention to apply to the Department of Immigration and Border Protection for migration to Australia Australian / New Zealand Yes / No Your approved pharmacy qualification 19 20 21 22 What is the name of your approved pharmacy qualification in English? What is the name of your approved pharmacy qualification in your own language? Name of Institution that awarded the Address of the Institution that awarded the 23 24 What language of instruction was used in your approved pharmacy What was the entry requirement for the course (or name of examination)? 25 26 Normal length of full time course semesters What was the length of time you took to complete the course? Number of years Number of semesters Length of semesters Years 27 Date course commenced / / Months Date course completed months / / 2
28 29 30 31 32 Was the course accelerated? (ie. was the course shortened?) Did you study part time or full time? How many hours per week did you study? Was a period of compulsory practice experience a requirement of the course? What was the length of time involved in the practical experience? (for example 1 year, 12 weeks or 40 semester hours) Part time Yes Full time Only complete the following section if you have more than 1 pharmacist qualification. 33 34 35 What is the name of your approved pharmacy qualification in English? What is the name of your approved pharmacy qualification in your own language? Name of Institution that awarded the No 36 Address of the Institution that awarded the 37 What language of instruction was used in your approved pharmacy 38 What was the entry requirement for the course (or name of examination)? 39 Normal length of full time course semesters Number of years Number of semesters Length of semesters months 40 What was the length of time you took to complete the course? Years Months 3
41 Date course commenced / / 42 43 44 45 46 Was the course accelerated? (ie. was the course shortened?) Did you study part time or full time? How many hours per week did you study? Was a period of compulsory practice experience a requirement of the course? What was the length of time involved in the practical experience? (for example 1 year, 12 weeks or 40 semester hours) Part time Yes Date course completed Full time No / / Registration 47 48 49 50 51 52 What is the name of your original registration authority? What country is this authority based in? What was your date of first registration? What is the name of the your most recent registration authority? What country is your most recent registration authority based? What is the date of your most recent registration / / (in dd/mm/yyyy format) / / (in dd/mm/yyyy format) 53 Provide the names of any professional bodies that you are a member of 4
Professional employment as a pharmacist If you want us to comment on your overseas work experience as a generally registered pharmacist you must fill out the following section. Please provide a summary below of your professional employment experience in the last 10 years. If the space provided is insufficient attached a signed sheet. Please include: The dates of each period of employment Confirmation of whether the work was full time (20+ hours per week) or part time (less than 20 hours per week) The name of the employer, the country you worked in and the nature of the business Your job title and description The duties or important tasks performed in the role 54 Payment of fees You are required to pay an assessment fee of AUD $700 which must accompany the application form. Fees for eligibility assessments are non-refundable. Fees must be in Australian Dollars and payable to the Australian Pharmacy Council Ltd. Payment Options (please tick which method of payment you will be using) Australian Cheque Australian Money Order Bank Draft (payable through an Australian Bank) Credit Card (Mastercard or Visa only)^ ^ Please note that a $10 processing fee applies to all credit card transactions 5
Checklist Note that Applicants must retain the original copy of all documents. They may be required to present those documents to other bodies such as registration authorities, employer or professional bodies. The APC reserves the right to request further information or documents in order to complete an assessment 2 recent passport sized photographs that are signed and dated on the back by the applicant. A certified photocopy of your identification document, eg. passport. A certified photocopy of your pharmacy qualification papers, eg. degree certificate. A complete certified photocopy of official transcript of educational courses completed showing subjects, results and where applicable, details of practical and clinical education. A certified photocopy of evidence of original and current registration or licence to practise. If your country does not have a legislative process for registration/licensure then you will need to forward an Australian Commonwealth Statutory Declaration. Please refer to the information under Commonwealth Statutory Declaration in this application form. An up-to-date Résumé or Curriculum Vitae (CV) Evidence of your professional work experience as a pharmacist in the last 10 years. Evidence should be provided for each position detailed on your Résumé or CV. References must be provided on the APC Work Experience Reference template that is available on the APC website. If self-employed, references from professional colleagues should be provided. Please note that APC will only calculate work experience you have undertaken as a registered retail/hospital pharmacist. Any work under 20 hours per week will not be calculated. While APC is authorised to comment on your qualifications and skilled employment, final decision to award points remains with the Department of Immigration and Border Protection. Applicants who do not wish the APC to comment on their work experience will need to provide an Australian Commonwealth Statutory Declaration to this effect. The statement must include the candidate s signature which has been witnessed by an authorised person e.g. Justice of Peace. Such candidates are not required to submit their Résumé / Curriculum Vitae (CV) or evidence (e.g. work references) of their professional work experience. A certified photocopy of Internship, if applicable. A certified photocopy of evidence of resident status in Australia (if you reside in Australia). Relevant pages from your passport showing personal details, visa entry and conditions or Australian Citizenship Certificate will suffice. A certified photocopy of evidence of change of name, eg. marriage certificate, deed poll (if applicable). A certified photocopy of translation in English of any documents originally issued in a language other than English. The APC will only accept translations completed by a translator accredited by the National Accreditation Authority for Translators and Interpreters (NAATI). The translated document must accompany a certified copy of the document in the original language. The certified copy of the document in the original language must also be stamped and signed by the NAATI translator. 6
Stream B Applicants Only A certified copy of evidence of your registration during the last ten years. Please arrange to have an original Certificate of current professional status (Letter of Good Standing) issued from each jurisdiction in which you have been registered in the last ten years. This Certificate should be sent directly to APC from the licensing body, or be provided in a sealed envelope. The seal of the licensing body must be unbroken. A certified photocopy of your current senior (or equivalent) first aid certificate issued by a valid issuer in either Australia or a country or jurisdiction recognised by the APC. The entire certificate must be completed face to face (study mode: full attendance). Additional information for applicants Agents Certification If you want someone to deal with APC on your behalf (eg. a migration agent, family member or friend), you will need to attach the original APC Agent Authorisation Form that is available on the APC website. Both you and your agent must sign the agent s authority. Please note that the APC will not correspond with an applicant when they have nominated an agent or a third party to act on their behalf. It is essential that: Black and white photocopies of documents are certified. APC must be satisfied that documents have not been amended or altered. To have your copies certified you will need to present both the original and the photocopy of each document to the person certifying them. Persons who may certify documents in Australia include Justices of the Peace and legal practitioners. Persons who may certify documents overseas include Justices of the Peace, official Notary Officers or an authorised staff member of an Australian Embassy or Consulate. Each page of every document must be certified separately and must show clearly: the words certified true copy of the original in the English language the signature, date and stamp of the certifying officer the name, address and contact details or provider/registration number (where appropriate) of the certifying officer legibly printed below the signature. Certified translations Please note it may be possible, from the details provided, for APC to contact the certifying officer if necessary. APC will not accept copies of documents which have been certified by an agent or a translator or an affiliate or employee of an agent or a relative acting on behalf of a candidate or by a provisionally or limited registered health practitioner. Please note: Certified translations in English of all documents must be provided and attached to the certified copy of the document to which they refer. 7
The APC will only accept translations completed by a translator accredited by the National Accreditation Authority for Translators and Interpreters (NAATI). Completing the form You will need to provide all the information and documents requested before your application can be finalised. You should answer all questions in English and initial and date any alterations to the form. Where there are name variances an Australian Commonwealth Statutory Declaration should be provided. For name changes, a certified copy of a marriage certificate or deed poll in supporting documents will suffice. Commonwealth Statutory Declarations Australian Commonwealth Statutory Declaration forms may be purchased at most newsagents or Australia Post offices or downloaded from the Australian Government Attorney-General s Department: http://www.ag.gov.au/publications/pages/statutorydeclarations.aspx. You will be able to download the Australian Commonwealth Statutory Declaration form in DOC or PDF format. If you are overseas, you must have the declaration witnessed by an authorised officer at an Australian Embassy or Consulate whom we may verify. If you are in Australia, a Justice of the Peace (JP) or any authorised person stated on the Australian Commonwealth Statutory Declaration may witness your declaration. Please provide the contact details of the certifying officer who will witness your statement and signature. You must forward the original Commonwealth Statutory Declaration form to the APC. Retention of application and documents Validity period The APC will keep all candidate documentation and information provided to the APC as part of the assessment process. All documentation provided to the APC for assessment purposes or used for making a determination of eligibility or issuance of a skills assessment letter will be retained by the APC in accordance with our Privacy Policy. A full copy of our Privacy Policy is available on the APC website. Effective 1 November 2014, the initial eligibility assessment has a validity period of three years for Stream A and Stream B candidates from the date on the eligibility letter. The APC will archive applicants files after that period if no progress is made through the APC process in that period. Candidates will need to re-apply for the eligibility assessment with all the required documentation and the full fee after their validity period expires. 8
Terms and Conditions Please read these Terms & Conditions carefully. You will need to agree to these terms and conditions before finalising your application. Evidence Appeals policy Privacy policy Confirmation of Terms You agree that all information, evidence and supporting documents you provide in this application (including of your identity, qualifications, registration and work experience) must be certified copies of the original documents. You must retain all original documents and you acknowledge that you may be required to present these to the APC if requested. If any document provided is not clear or complete, then the APC reserves the right to reject the document and/or request further information to verify the information provided. APC may also request further information from time to time in order to complete the assessment process. You agree that all evidence or supporting documents you provide to APC throughout this process are complete, correct and up-to-date. Providing APC with any incorrect or misleading information prior to, during, or after the assessment process may result in APC amending or withdrawing any decision on your eligibility or competency to practice. You agree that the APC Appeals Policy (www.pharmacycouncil.org.au/library/policies-andguidelines) applies to this application for assessment. The APC may collect, use and disclose your personal information to perform the APC s functions (including the assessment of credentials) and for the purposes of improving educational offerings, in circumstances related to the public interest, for the purposes of law enforcement and public or individual safety. The APC may collect that information from you or third parties such as your educational institution or previous workplaces. Disclosure of information collected may be to third parties including the Australian Health Practitioner Regulation Agency, Pharmacy Board of Australia, your intern program provider or your professional body. Applicants have a number of rights under Privacy legislation including the right to access the personal information that the APC may hold about them. To access full details please refer to the APC Privacy Policy (www.pharmacycouncil.org.au/library/policies-and-guidelines). By completing the application process you agree to the APC s Privacy Policy. APC reserves the right to change these Terms & Conditions from time to time, including any APC policy which is incorporated into these Terms by reference, and you agree to be bound by any such changes when they are posted on APC s website. Candidate Acceptance and Declaration You must make the following Declarations and Authorisations to continue with the application process. I declare that: My registration or licensure as a pharmacist in any jurisdiction or in any country has never been suspended, cancelled or had conditions imposed on it; and 9
I have never been refused registration or licensure as a pharmacist in any jurisdiction or in any country. Signature Date If you have had your registration or licensure as a pharmacist in any jurisdiction or in any country suspended, cancelled or had conditions imposed on it or you have been refused registration or licensure as a pharmacist in any jurisdiction or in any country you will need to provide details in the space below and upload any supporting documents: I declare that: I have read and understood these Terms & Conditions, including the Australian Pharmacy Council s Policies and any explanatory notes; The information I have supplied in this application process and in any attachments is complete, correct and up-to-date and is not misleading; I undertake to inform the Australian Pharmacy Council of any changes to my circumstances or personal information (e.g. address or qualifications) as soon as possible after the change and in any event, no later than the assessment of my application by the Australian Pharmacy Council; If there are any changes to my circumstances after the Australian Pharmacy Council has assessed my application (including any change to the status of my registration, licensing or qualifications) then the Australian Pharmacy Council has the right to modify their assessment of my eligibility or competency; and I meet the eligibility requirements set out on the Australian Pharmacy Council website. I accept these Terms and Conditions and make the Declarations listed above. I do not accept these Terms and Conditions and I do not make the Declarations listed above. I authorise the Australian Pharmacy Council to: make any enquiries necessary (including enquiries to third parties including educational institutions, registration or licensing boards, employers or referees and certifying officers etc.) to assist in verifying the accuracy of the information provided by me, including verification of my eligibility to be assessed for registration; and 10
disclose the information provided by me in this assessment registration process (and in any supporting documents provided) as detailed in the Australian Pharmacy Council s Privacy Policy. I hereby give the authorisations above to the Australian Pharmacy Council. I do not give the authorisations above to the Australian Pharmacy Council. Signature Date 11