Western Australian Consolidated Regulations

HEALTH (NOTIFICATIONS BY MIDWIVES) REGULATIONS 1994 - SCHEDULE

FORM 1

[reg. 3]

HEALTH ACT 1911

HEALTH (NOTIFICATIONS BY MIDWIVES) REGULATIONS 1994

NOTIFICATION OF INTENTION TO ENTER INTO PRIVATE PRACTICE AS A MIDWIFE

EXECUTIVE DIRECTOR
PUBLIC HEALTH

I intend to enter into private practice as a midwife on ..........................................
20 .......................

PERSONAL PARTICULARS

Full Name: .............................................................................................................

Date of Birth: .........................................................................................................

*Private/*Business Address: ..................................................................................

*Private/*Business Telephone No.: .......................................................................

Australian Health Practitioner Regulation Agency Registration No.: ...................

...............................................
Signature

...............................................
Date

*Delete if not applicable

        [Form 1 amended in Gazette 1 Apr 2011 p. 1178 .]

FORM 2

[r. 4]

        [Form 2 inserted in Gazette 30 Dec 2011 p. 5578 .]