One-on-One Workshop 1.3

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Phone Number

Mailing Address

Emergency Contact Name

Emergency Contact Phone Number

Citizenship or Residency Status

New Zealand Citizen

Permanent Resident

Other

Licence or Practicing Certificate

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Are you Under Investigation?

Yes

No

Are you being investigated by Health and Disability Commission or Medical Commission or Nursing Council?

Current CPR/Resuscitation certificate?

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Please upload your current CPR/Resuscitation certificate

Practice Insurance

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Please upload copy of practice Insurance

Education List of Tertiary Qualifications, Institutions and dates attended.

Workshops