Register your interest for participation in the NT Emergency Initiative

Personal details
Name
Telephone (after hours)
Telephone (business hours)
Telephone (mobile)
Fax Number
E-mail address
Postal address: Street
Suburb
State/Territory
Postcode
Gender	Male Female
Do you identify as Aboriginal and/or Torres Strait Islander?	Yes No
Professional information
Expression of interest as	Doctor Allied Health Professional Dentist Registered Nurse Enrolled Nurse Admin worker (with health care experience) Aboriginal Health Worker

Additional information
Please indicate your experience	Paediatrics Indigenous Health Sexual Health Remote Area Work in Indigenous communities Administration Alcohol and drugs Maternal and Child Health Mental Health Other
Current professional practice (select one)	Currently in active clinical practice (>2 days/week on average) Currently in active clinical practice (<=2 days/week on average) Not currently in active clinical practice
Are you a member of a professional organisation/group?	Yes No
Availability dates (Minimum 3 weeks preferred and multiple deployments may be possible)	Available anytime or Available for periods (choose to select available dates)
	Available for long-term secondment/locum
Registration information
Are you registered?	Yes No
Where are you registered?	ACT NSW VIC QLD SA WA NT TAS
Registration type	Conditional Unconditional
	I understand that prior to undertaking work, some mandatory requirements will need to be met eg. police check, NT registration.
	I confirm that, if selected to participate, I am willing and able to work in potentially difficult conditions.
	I confirm that I have read, and agree to, the privacy and security statement.