Read Microsoft Word - MELB GRAD Graduate Certificate of Good Character.doc text version

PO Box 248 Collins Street West Vic 8007 STD: 1300 61 487

T: +61 3 9286 1888 F: +61 3 9286 1880 E: [email protected] W: physioboard.vic.gov.au

CERTIFICATE OF GOOD CHARACTER

Applicants for registration are required to supply a Certificate of Good Character from one referee. The certificate should be completed by a physiotherapist, a medical, dental or legal practitioner, a minister of religion or a commissioned officer in the armed services - or any other person qualified to take a Statutory Declaration in Victoria. The referee must not be related to the applicant. The referee must have known the applicant for at least 12 months. Full name of the applicant Details of the Referee: Name: ________________________________________________________________________ Relationship to the applicant: ________________________________________ Occupation: ______________________________________________________ Address: ______________________________________________________________________ Telephone numbers: (W) ___________________ (H) ___________________ Facsimile numbers: (W) ___________________ (H) ___________________ The Referee is asked to complete the following: · · · · · I have known the applicant for _________________ years. Does the applicant have any criminal convictions that you know of? ___________ Do you consider the applicant to be of good character? _______________

(YES/NO) (YES/NO) (YES/NO)

________________________________________________________

Do you consider the applicant to be suitable for registration? _______________ Please comment on any other matters that you consider to be pertinent:

______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ I agree to supply additional information if required by the Board.

______________________________ Signature

PRBV500/APP FORMS/2008/MELBGRAD

________________________ Date

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Microsoft Word - MELB GRAD Graduate Certificate of Good Character.doc

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