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Application Process

Complete the Online Form: Fill out the digital application form and attach all required documents.
Submit Your Application: Once completed, your application and supporting documents will be submitted for review.
Approval and Confirmation: Your application will be reviewed, and you’ll be notified of the outcome via email.

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Personal Information

First Name

Last Name

Degrees / Qualifications

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date of Birth

YYYY

Country of Citizenship

Microsurgical Experience and Practice

Current Surgical Positions

Year of attaining Specialist Qualification

Number of Free Tissue transfers in the past 12 months

Number of Free Tissue transfers in career

Number of other microsurgical procedures in past 12 months

Publications

Referee – Proposer

(Must be a member of AUSRM)

First Name

Last Name

Phone

(###)

###

####

Referee – Seconder

(Must be a Member of AUSRM)

First Name

Last Name

Phone

(###)

###

####

Submission Date

YYYY

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