Australian Medical Council Limited

MCQ EXAMINATION FORM

APPLICATION FOR AUTHORISATION TO SCHEDULE FOR AN MCQ EXAMINATION EVENT
CANDIDATE NUMBER OFFICE USE ONLY Date Received Stamp

Name [Surname/ Family Name] Given Name[s] Address

Male

Female

[State]

[Post Code]

[Country]

Telephone Details: Please ensure to add the country and area codes where applicable Home [ Country Code] [Area Code] Mobile [Country Code] [Area Code] Email Address: Fax Work [ Country Code] [Area Code]

FEES: The fee for this examination event is AU$2100-00.

PAYMENT OPTIONS:

Candidate examination fees are GST free.

PLEASE PRINT CLEARLY

TYPE OF CREDIT CARD:
CARD HOLDERS NAME CREDIT CARD NUMBER CARD EXPIRY DATE CARD HOLDERS SIGNATURE

SA

Cheque payment: Cheque should be made payable to the Australian Medical Council Ltd. both MCQ Examination Form (Application for Authorisation) and cheque should be sent to the AMC by mail. Please note: Dishonoured cheques will incur administration fee. AEI-NOOSR Assessment Subsidy for Overseas Trained Professionals Program (ASDOT) payment: Both the MCQ Examination Form (Application for Authorisation to schedule for an MCQ examination event) and the original AEI-NOOSR ASDOT Agreement to Pay should be sent to the AMC by mail. The AEI-NOOSR ASDOT Agreement to Pay will identify the MCQ examination event authorised for payment by AEI-NOOSR through ASDOT. A candidate can only apply for ASDOT assistance for ONE MCQ examination event. If the candidate does not show for the MCQ examination event for which an ASDOT Agreement to Pay has been issued, the AMC will claim full payment from AEI-NOOSRs ASDOT program and the candidate will forfeit further ASDOT funding for an MCQ examination event. Credit Card payment: Please complete below and send to the AMC via email or fax. Please note: Please only send by fax or email to avoid double-up payment.

Please note: Recording the expiry date will be taken as consent to record the credit card details and process payment.

M
Mastercard

PL
Visa

Month

E
Page 1

[ Country Code] [Area Code]

Year DATE

PRIVACY
Your privacy is respected by the AMC. Information collected by the AMC may be used for administering the AMC Examination and provided to AMC Examiners and the Australian and Territory Medical Boards. The AMC privacy procedures are set out in a Policy Statement which can be obtained from the AMC. If you have any privacy concerns or would like to verify information held about you, please contact the Privacy Officer, Australian Medical Council Limited, PO Box 4810, KINGSTON ACT 2604, AUSTRALIA. I wish to apply for authorisation to schedule for an AMC MCQ examination event and certify that I have familiarised myself with the requirements for the AMC Examination as set out in the AMC publications (AMC Website and Examination Specifications Booklet). I acknowledge that my eligibility to sit for the AMC MCQ examination is conditional upon my satisfactory completion of the eligibility requirements to sit the examination, including Primary Source Verification, set out in the Procedures and Requirements for the AMC Examination information booklet (the information booklet). I acknowledge that any failure by me to complete the requirements to sit the MCQ examination, or any problems with Primary Source Verification of my qualifications documents, may result in the AMC withdrawing my candidature as being eligible to sit the MCQ examination and I also acknowledge that the AMC will withhold my results of an MCQ examination completed by me until such time as I satisfactory meet the eligibility requirements to sit the MCQ examination set out in the information booklet and as determined by the AMC.

AUTHORISATION AND SCHEDULING PROCESS

Seating in all Pearson VUE examination venues are limited, and candidates will be scheduled on a first come first serve basis. Please refer to the AMC website for a list of available venues. Please note that if you have not selected an MCQ examination event by the end of your authorisation period, you will forfeit your authorisation as well as your examination fee and will need to re-apply with full payment.

SA
Candidates signature (MUST be signed)
Australian Medical Council PO Box 4810 Kingston ACT 2604 AUSTRALIA

Transfer from MCQ examination event and/or examination venue: If you wish to transfer or cancel from an MCQ examination event or change venue, you must contact Pearson VUE for assistance. You do not need to complete the MCQ Examination Notification to Cancel Authorisation Form (available on AMC website). Cancellation of your authorisation to schedule: If you wish to cancel your MCQ Examination authorisation, you must complete the MCQ Examination Notification to Cancel Authorisation Form in order for a refund, less an administration fee, of your examination payment. OTHER: - Transfer/cancel from MCQ examination event by contacting Pearson VUE before closing date NO penalties payable - Transfer/cancel from MCQ examination venue by contacting Pearson VUE before closing date .. NO penalties payable - Transfer/cancel from MCQ examination event and/or venue after closing date .......... NO refund - Failure to attend selected MCQ examination event ........................................................................................................... NO refund - Failure to confirm MCQ examination event and/or venue by end of MCQ Examination authorisation .... NO refund I hereby confirm that I understand and agree to the AMC MCQ examination processes and penalties as outlined above:

All applications with payment must be forwarded to:

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EXAMINATION FEE PENALTIES Contact details:
Telephone: Facsimile: E-mail: AMC website: Page 2

It is up to you as the candidate to read all the information included with the instructions email and contact Pearson VUE in order to be scheduled in an examination event. You can transfer between any of the MCQ examinations covered in your authorisation by contacting Pearson VUE or by using the Pearson VUE scheduling system Pearson VUE will send you an email with your login details. No penalties will be charged for changes made in MCQ examination or venue, provided it has been done PRIOR to the MCQ examination closing date as listed on the AMC website.

Once the AMC receives your MCQ Examination Form (Application for Authorisation), the examination fee is processed at the AMC office and an instructions email will be sent to you with information on how to schedule for an AMC MCQ examination event and venue through Pearson VUE. (Please ensure that your email address on the front of this form is current and written clearly). You will be issued with one authorisation which will allow you to schedule in one of the MCQ examinations covered in your authorisation. Full details of all MCQ examinations covered in your authorisation will be sent to you by email.

(+61) (0) 2 6270-7878 (+61) (0) 2 6270-9799 mcq@amc.org.au www.amc.org.au