APRO-76

* A PR O - 7 6 1 *

Application for provisional registration
Profession: Psychology
Part 7 Division 6 of the Health Practitioner Regulation National Law (the National Law)

This form is for individuals applying for provisional registration to enable them
to undertake the period of supervised practice required to be eligible to apply
for general registration.
An applicant for provisional registration must have completed, within the
past ten years, a four-year sequence of study in psychology accredited
by the Australian Psychology Accreditation Council (APAC), or a sequence
of study that has been assessed by the Psychology Board of Australia’s (the
Board) accreditation authority as substantially equivalent.
There are four distinct pathways available for completion of the required
supervised practice:
• The higher degree pathway: a fifth and sixth-year APAC accredited
higher degree leading to general registration (i.e. Masters, Doctorate, or
combined Masters/PhD), or
• The 5+1 internship program: a fifth year APAC accredited degree (i.e.
Graduate Diploma of Professional Psychology), followed by a one year
Board-approved internship, or
• The 4+2 internship program: a four year APAC-accredited degree,
followed by a two year Board approved internship (4+2), or
• The overseas qualifications pathway: qualifications that are assessed as
equivalent to an APAC accredited six year sequence of study in psychology
and completion of a Board approved transitional program.
Note, each pathway is distinct and components from two or more pathways
cannot be combined to meet the supervised practice requirement for
general registration.
It is important that you refer to the Board’s registration standards, codes and
guidelines before completing this application. These documents can be found
at www.psychologyboard.gov.au
T his application will not be considered unless it is complete and
all supporting documentation has been provided. All academic
transcripts and evidence of university enrolment must be
original documents and must be sent directly to the Australian
Health Practitioner Regulation Agency (AHPRA) by the issuing
educational institution. Supporting documentation must be certified
in accordance with AHPRA guidelines. See Certifying documents in
the Information and definitions section of this form.

Privacy and confidentiality
The Board and AHPRA are committed to protecting your personal information in
accordance with the Privacy Act 1988 (Cth). The ways the Board and AHPRA may collect,
use and disclose your information are set out in the collection statement relevant to this
application, available at www.ahpra.gov.au/privacy.
By signing this form, you confirm that you have read the collection statement. AHPRA’s
privacy policy explains how you may access and seek correction of your personal
information held by AHPRA and the Board, how to complain to AHPRA about a breach of
your privacy and how your complaint will be dealt with. This policy can be accessed at
www.ahpra.gov.au/privacy.

Symbols in this form
Additional information
Provides specific information about a question or section of the form.
Attention
Highlights important information about the form.
Attach document(s) to this form
Processing cannot occur until all required documents are received.
Signature required
Requests appropriate parties to sign the form where indicated.
Mail document(s) directly to AHPRA
Requires delivery of documents by an organisation or the applicant.

Completing this form
• Read and complete all questions.
• Ensure that all pages and required attachments are returned to AHPRA.
• Use a black or blue pen only.
• Print clearly in B L O C K

L E T T E RS

• Place X in all applicable boxes:
• DO NOT send original documents unless specified
D 
o not use staples or glue, or affix sticky notes to your application.
Please ensure all supporting documents are on A4 size paper.

SECTION A: Personal details
The information items in this section of the application marked with an asterisk (*) will appear on the public register.
1. What is your name and date
of birth? 
If you have ever been
formally known by another
name, or you are providing
documents in another name,
you must attach proof of your
name change unless this has
been previously provided to
the Board.

For more information, see
Change of name in the
Information and definitions
section of this form.

Title*
MR

MRS

MISS

MS

DR

OTHER

SPECIFY

Family name*
First given name*
Middle name(s)*
Previous names known by (e.g. maiden name)

Date of birth

D D / MM / Y Y Y Y

Effective from: 9 September 2014

Page 1 of 12

• You must only use each document once. For documents translated in Australia. • Australian birth certificate extracts are not accepted.*APRO-762* APRO-76 2. I have used a Category B or C document that has my current residential address You must attach a certified copy of all proof of identity documents that you have indicated above.au For documents translated overseas. details – credit or ATM card NA NA Electoral enrolment card A document from Category D is only required if your Category B or C document does not provide evidence of your residential address. visa PAYG payment summary NA NA Australian birth certificate NA Motor vehicle registration NA NA Current Australian visa NA Financial institution statement NA NA Australian Armed Services papers NA Taxation assessment notice NA NA Travel documents with Aust. Please indicate on the chart below which piece of evidence you are submitting for each category and attach the certified copies of documents to your application. you must also provide evidence from category D. a certified copy of the identity information page (the photo page) must be provided.ahpra. the translator must be accredited by NAATI – see www. can be found in the AHPRA Proof of identity requirements document under the heading What special circumstances apply to overseas applicants or applicants who have recently arrived in Australia? This document is available at www. • If using your passport. Choose proof of identity documents to submit: (A document may only be used once for any category) Documents Category used: A B C Documents Category used: A B C Australian passport Medicare card NA NA Overseas passport with current Aust.org for a list of authorities who provide certified translations.au/identity • You must provide evidence from category A. Which documents from each category will you provide for proof of identity? T he documents provided must meet the following criteria: • At least one document must be in the applicant’s current name.com.gov. or those who have recently arrived in Australia. and C. W  hat are your birth and personal details? Country of birth City/Suburb/Town of birth State/Territory of birth (if within Australia) VIC Sex* MALE NSW QLD SA WA NT TAS ACT FEMALE Languages spoken other than English (optional)* SECTION B: Proof of identity You must provide proof of your identity with this application The minimum requirements for overseas applicants. Effective from: 9 September 2014 Page 2 of 12 .ahpra.au/translate for further information.naati. see www. • All documents must be officially translated into English. 3. Please refer to Translating documents at www. • All documents must be true certified copies of the original. • Your category B document must have a recent photo. See Certifying documents in the Information and definitions section of this form for more information. B. • If your evidence from category C or B does not include your residential address.fit-ift. visa NA Health insurance card NA NA Australian citizenship certificate NA Pension card NA NA Category D documents Australian driver licence NA Working with children check card NA Firearm or shooters licence NA Student ID card NA International driver licence NA Proof of age card NA Change of name certificate NA NA Mortgage papers Australian marriage certificate NA NA Rate notices Australian divorce papers NA NA Lease or tenancy agreement Board registration certificate NA NA Utility account Bank acct.gov.

Address (e. 30 JAMES STREET) City/Suburb/Town* State or territory (e.*APRO-763* APRO-76 SECTION C: Contact information O  nce registered.gov.ahpra. 123 JAMES AVENUE. or Address (e. VIC.g. VIC. 30 JAMES STREET) • your principal place of residence. What is your residential address? Site/building and/or position/department (if applicable) When you are not yet practising. or UNIT 1A.au and • download and complete the change of address form CHDT-00 – Request for change of address details on the register. and • the information items marked with an asterisk (*) will appear on the public register as your principal place of practice. ACT) Postcode* Effective from: 9 September 2014 Page 3 of 12 . 4.g. Principal place of practice cannot be a PO Box. or UNIT 1A. The information items marked with an asterisk (*) will appear on the public register. or • log in to your AHPRA account to change your details online.g.g. Mobile Business hours After hours Email 5. if you are not practising the profession or are not practising the profession predominantly at one address. City/Suburb/Town* State/Territory* (e. Refer to the question below for the definition of principal place of practice. or when you are not practising the profession predominantly at one address: • your residential address will be recognised as your principal place of practice. 123 JAMES AVENUE. Please go to www. you can change your contact information at any time. What are your contact details? Provide your current contact details below – place an next to your preferred contact phone number. W  ill the address of your principal place of practice be the same as your residential address? YES NO Provide your Australian principal place of practice below Site/building and/or position/department (if applicable)  Principal place of practice for a registered health practitioner is: • the address at which you will predominantly practise the profession. ACT)/International province* Postcode/ZIP* Country (if other than Australia) 6. Residential address cannot be a PO Box.

*APRO-764* APRO-76 7. which has been agreed by the applicant for provisional registration and the principal and secondary supervisors. 123 JAMES AVENUE. or UNIT 1A. Registration as a provisional psychologist for overseas trained applicants who hold qualifications equivalent to a six-year accredited sequence of study in psychology in Australia is dependent on the Board being satisfied that the applicant: • meets the mandatory registration standards. and • is currently enrolled in an APAC-accredited fifth year degree and evidence of enrolment is provided directly to AHPRA by the educational institution. My residential address My principal place of practice Other (Provide your mailing address below) Site/building and/or position/department (if applicable) Address/PO Box (e. Registration as a provisional psychologist for applicants undertaking an APAC accredited higher degree leading to general registration is dependent on the Board being satisfied that the applicant: • meets the mandatory registration standards • has completed an APAC-accredited four-year sequence of study (or its equivalent) in psychology. and • has proposed a supervised practice program that is consistent with the Guidelines for 4+2 internship programs for provisional psychologists and supervisors. What is your mailing address?  Your mailing address is used for postal correspondence. Following completion of the fifth year degree continuation of provisional registration will be dependent on: • submission of evidence by the educational institution of successful completion of all components of the fifth year degree and eligibility to graduate. and • has proposed a supervised practice program that meets the requirements of the Transitional Program set out in the Policy for overseas qualified applicants for registration. or PO BOX 1234) City/Suburb/Town State or territory (e. VIC.g. which has been agreed to by the provisional psychologist and the principal and secondary supervisors.g. ACT)/International province Postcode/ZIP Country (if other than Australia) SECTION D: Qualification for provisional registration Registration as a provisional psychologist under the 4+2 internship program pathway is dependent on the Board being satisfied that the applicant: • meets the mandatory registration standards • has completed an APAC-accredited four-year sequence of study (or its equivalent) in psychology in the past ten years at the time of application. and • is currently enrolled in an APAC-accredited higher degree and evidence of enrolment is provided directly to AHPRA by the educational institution. 30 JAMES STREET. and • submission of a proposed supervision plan that is consistent with the Guidelines for the 5+1 internship program. Effective from: 9 September 2014 Page 4 of 12 . Registration as a provisional psychologist under the 5+1 internship program pathway is dependent on the Board being satisfied that the applicant: • meets the mandatory registration standards • has completed an APAC-accredited four-year sequence of study (or its equivalent) in psychology in the past ten years at the time of application. Note: for applicants not currently residing in Australia the Board may consider granting provisional registration with conditions to enable a transition program to be arranged once the applicant arrives in Australia.

*APRO-765* APRO-76 8. 9. and hours of work. This must: –– be on the letterhead of the organisation that is proposing to employ you for the purposes of supervised practice. Effective from: 9 September 2014 Page 5 of 12 . and –– include at least a brief description of your work role. and be signed by an authorised person in the workplace. responsibilities and reporting requirements. see Certifying documents in the Information and definitions section of this form. including duties. YES NO All my qualifications listed above are accredited Australian qualifications You must attach a certified copy of the assessment of your overseas qualifications from the Australian assessing authority for overseas qualifications in psychology (the Australian Psychological Society). Have you completed an overseas qualification that is substantially equivalent to a four-year APAC-accredited sequence of study in psychology in Australia? Attach a separate sheet if all your qualification details do not fit in the space provided. Are you applying to undertake YES a 4+2 internship program?  NO Go to the next question Attachment required below – then go to question 15 You must attach: • a completed Supervised practice plan for provisional registration as a psychologist (4+2 internship program) .SPPR-76 to provide detailed information about your planned program.  Note: this is in addition to your arranging for your transcripts to be sent directly to AHPRA by the issuing institution. 10. and • a copy of your position description(s) relating to the proposed supervised practice program. What are the details of your qualifications meeting the provisional registration standard? Most recent qualification and examinations/assessments Title of qualification Name of institution (University/College/Examining body) For more information.  You may be required to submit additional information to assist with the Board’s assessment of your qualifications. Country Start date Completion date MM / Y Y Y Y MM / Y Y Y Y Additional qualification and examinations/assessments Title of qualification Name of institution (University/College/Examining body) Country Start date Completion date MM / Y Y Y Y MM / Y Y Y Y You must arrange to have the original transcript of your academic qualifications sent directly to AHPRA by the issuing institution.

If you are not currently residing in Australia. Only the following forms of evidence will be accepted: • an official university or higher education institution document (transcript or letter from Head of School) confirming your current enrolment.  ou must choose your pathway. the Board may consider an application without AATP-76 . In such cases. This must: • be signed by your proposed supervisor. • a completed Internship program plan (5+1 internship) . the Board may propose to grant you provisional registration with a condition that you do not practise in Australia until form AATP-76 is provided and approved by the Board. Effective from: 9 September 2014 Page 6 of 12 .Application for approval of a transitional program. following completion of the Graduate Diploma of Professional Psychology. Are you applying to undertake YES a 5+1 internship program? NO Go to the next question Provide details of your degree and attachments below – then go to question 15 Title of qualification (degree) Name of institution (University/College/Examining body) You must arrange for evidence of your current enrolment in an APAC-accredited fifth year qualification (e. A letter of offer does not constitute evidence of enrolment. 11. or • a print-out of your enrolment record (only if your Head of School has separately sent us a list of enrolled students confirming your enrolment). or • a print-out of your enrolment record (only if your Head of School has separately sent AHPRA a list of enrolled students confirming your enrolment). A letter of offer does not constitute evidence of enrolment. Only the following forms of evidence will be accepted: • an official university or higher education institution document (transcript or letter from Head of School) confirming your current enrolment.*APRO-766* APRO-76 11. and • a copy of your position description(s) relating to the proposed supervised practice program. Are you applying to undertake YES a three month Transitional Program as required by the Policy for overseas qualified applicants for registration? NO You must attach form AATP-76 – Application for approval of a transitional program to provide detail of your proposed Transitional Program. you will be required to submit the following before progressing to the internship year of the 5+1 program: • evidence of successful completion of all the requirements of the degree and eligibility to graduate. your provisional registration may not be renewed. Y 12 and 13. Graduate Diploma of Professional Psychology) to be sent directly to AHPRA by the issuing institution.INPP-76 to provide detailed information about your planned internship program. and • attach a copy of the position description/s for the proposed supervised practice work role(s). 12. Are you applying to undertake YES NO Go to the next question an APAC-accredited higher degree at fifth and sixth Provide details of your degree and attachments below – then go to question 15 year leading to general Title of qualification (degree) registration? Name of institution (University/College/Examining body) You must arrange for evidence of your current enrolment to be sent directly to AHPRA by the issuing institution. If this condition is not met within 12 months of your registration being approved. You must answer YES to one of questions 10.g. 13. You should also note that.

Refer to www. YES NO Provide a separate sheet with details of your criminal history in another country and explanation of circumstances. Refer to www.gov.psychologyboard. However. For more information. Attach a separate sheet if all your registration history does not fit in the space provided. Refer to the Information and definitions section of this form and the Recency of practice registration standard in the Standards and guidelines section of the website. Profession Period of registration D D / M M / Y Y Y Y to D D / M M / Y Y Y Y  If you have been registered outside of Australia. Have you undertaken psychological practice in the last five years? T he Board’s Recency of practice registration standard requires that applicants have recent psychological practice experience within the last five years.au/About-AHPRA/Contact-Us for your AHPRA state office address. YES NO You may be required to undertake other remedial action to meet the Board’s recency of practice You must attach your signed and dated curriculum vitae outlining your practice history. Additional registration State/Territory/Country Profession Period of registration D D / M M / Y Y Y Y to D D / M M / Y Y Y Y If you have been registered outside of Australia. registered as a health practitioner.ahpra. It is recommended that you provide as much information as possible to enable the Board to reach a timely and informed decision. see Criminal history in the Information and definitions section of this form. Do you have any criminal history in Australia? It is important that you have a clear understanding of the definition of criminal history. and the requirements set out in the Board’s registration standards. SECTION F: Suitability statements Information required by the Board to assess your suitability for registration is detailed in the following questions. or have been previously. or have previously been registered as a health practitioner during the past five years. standard – refer to the Recency of practice registration standard and the Policy for recency of practice requirements in the Standards and guidelines section of the website. you must arrange for original Certificates of Registration Status or Certificates of Good Standing to be forwarded directly from the registration authority to your AHPRA state office.au/Registration-Standards for further information. Please note that registration is dependent on suitability as defined in the National Law. Do you have any criminal history in another country? For more information. YES Go to question 22 NO Go to the next question Effective from: 9 September 2014 Page 7 of 12 . 17. the Board will contact you.*APRO-767* APRO-76 14. What is your health practitioner registration history? Most recent registration State/Territory/Country Registration history only applies if you are currently. YES NO Provide a separate sheet with details of your criminal history in Australia and explanation of circumstances. Have you previously been registered to practise as a psychologist in Australia? If you have previously been registered to practise as a psychologist in Australia you have met the requirements of the Board’s English language skills registration standard. SECTION E: Registration history 15. In such a case.gov. the Board may still require you to provide evidence of your English language skills. the Board requires a Certificate of Registration Status or Certificate of Good Standing from every jurisdiction outside of Australia in which you are currently. 16. 18. see Criminal history in the Information and definitions section of this form.

see Professional indemnity insurance in the Information and definitions section of this form. 21. YES YES 25. your capacity to practise the profession? 24. Effective from: 9 September 2014 Page 8 of 12 .APRO-76 19. in one of the countries listed? • Australia • Canada • South Africa • United Kingdom YES NO *APRO-768* • Republic of Ireland Go to the next question Attachment required below – then go to question 22 F or more information. NO You must attach to this application details of any registration suspension or cancellation. Do you commit to having arrangements in place when practising. indemnity insurance arrangements in place for all practice undertaken during YES NO the registration period? 23. appropriate professional For more information. or is likely to detrimentally affect. Have you previously had your YES registration cancelled. in English. refused or suspended in Australia (under the National Law or a corresponding prior Act) or overseas? NO You must attach to this application details of any impairments and how they are managed. You must send a certified copy of your Board-approved English language test results to your AHPRA state office. Have your results from the above mentioned English language examination been obtained within two years prior to applying for registration?  • New Zealand • United States of America YES NO You must attach evidence that you have actively maintained employment as a registered health practitioner using English as the primary language of practice in one of the following countries: • Australia • Republic of Ireland • United States of America • Canada • South Africa • New Zealand • United Kingdom Applicants who have not achieved their results within two years prior to applying for registration or are unable to provide evidence of actively maintaining employment using English as the primary language in one of the countries listed above are ineligible for registration. by secure internet login). Pass result must be obtained in one sitting. AHPRA will verify your test results directly with the testing authority (for example. NO You must attach to this application details of any cancellation or refusal. see Impairment in the Information and definitions section of this form. You must submit a certified copy of the original evidence of having undertaken your secondary education in English. Please provide the test report form number for your International English Language Test System (IELTS) – Academic module examination. Do you have an impairment that detrimentally affects. Applicants unable to meet this requirement are ineligible for registration. see English language skills in the Information and definitions section of this form. Did you undertake and complete your secondary education and your tertiary qualifications in the profession. Is your registration in any profession currently suspended or cancelled in Australia (under the National Law or a corresponding prior Act) or overseas? For more information.  The Board requires all applicants for provisional registration to have appropriate professional indemnity 22. 20. reading. International English Language Test System (IELTS) Academic module Test report form number: The Board requires an IELTS Academic module score of at least 7 in each of the four components (listening. writing and speaking).

or f) the practitioner’s authority under a law of a State or Territory to administer. obtain. b) if the practitioner is employed by another entity— (i) the name of the practitioner’s employer. address or name 6. within 30 days of any of the following changes happening. or e) the practitioner’s billing privileges are withdrawn or restricted under the Human Services (Medicare) Act 1973 (Cth) because of the practitioner’s conduct. A registered health practitioner must not practise the health profession in which the practitioner is registered unless appropriate professional indemnity insurance arrangements are in force in relation to the practitioner’s practice of the profession. Effective from: 9 September 2014 professional performance or health. For more information. within 7 days after becoming aware that a relevant event has occurred in relation to the practitioner. h) the practitioner’s registration under the law of another country that provides for the registration of health practitioners is suspended or cancelled or made subject to a condition or another restriction. punishable by imprisonment. as detailed at points 1. or d) the practitioner’s right to practise at a hospital or another facility at which health services are provided is withdrawn or restricted because of the practitioner’s conduct. without reasonable excuse. give the National Board that registered the practitioner written notice of the event. Professional indemnity insurance arrangements 2. Continuing professional development 1. conduct or performance action may be taken by the Board. A registered health practitioner must. YES YES NO You must attach to this application details of any disqualifications. Obligations of registered health practitioners The National Law pt 7 div 11 sub-div 3 establishes the legislative obligations of registered health practitioners. Have you been. supply or use a scheduled medicine or class of scheduled medicines is cancelled or restricted. fail to comply with a written notice given to the practitioner under point 3 above. A National Board may. ask the practitioner to give the Board the following information— a) information about whether the practitioner is employed by another entity. 2. Has your registration ever been subject to conditions. Employer’s details 7. SECTION G: Obligations and consent Before you sign and date this form. C  o-regulatory jurisdiction means a participating jurisdiction (of the National Law) in which the Act applying (the National Law) declares that the jurisdiction is not participating in the health. see the Information and definitions section of this form. and (ii) the address and other contact details of the practitioner’s employer.*APRO-769* APRO-76 26. whether in a participating jurisdiction or elsewhere. codes and guidelines. 4. Are you disqualified from applying for registration. the subject of conduct. (ii) an entity performing functions under the Health Insurance Act 1973 (Cth). without reasonable excuse. or being registered. undertakings or limitations. possess. State or Territory entity having functions relating to professional services provided by health practitioners or the regulation of health practitioners. or the law of another jurisdiction in Australia or overseas. (iv) the Secretary to the Department in which the Migration Act 1958 (Cth) is administered. where those proceedings were not finalised? YES NO You must attach to this application details of any conditions. performance and conduct process provided by Divisions 3 to 12 of Part 8 (of the National Law). A contravention of these obligations. a corresponding prior Act. fail to comply with the notice. or are you currently. b) a change in the address provided by the registered health practitioner as the address the Board should use in corresponding with the practitioner. Relevant event means— a) the practitioner is charged. at any time by written notice. c) a change in the practitioner’s name. with an offence punishable by 12 months imprisonment or more. or g) a complaint is made about the practitioner to the following entities— (i) the chief executive officer under the Human Services (Medicare) Act 1973 (Cth). or b) the practitioner is convicted of or the subject of a finding of guilt for an offence. or c) appropriate professional indemnity insurance arrangements are no longer in place in relation to the practitioner’s practice of the profession. prescribe. give the National Board that registered the practitioner written notice of the change and any evidence providing proof of the change required by the Board— a) a change in the practitioner’s principal place of practice. or overseas? 28. (v) another Commonwealth. Registered health practitioners are also obligated to meet the requirements of their Board as established in registration standards. performance or health proceedings. An incomplete form may delay processing and you may be asked to complete a new form. require a registered health practitioner registered by the Board to give the Board evidence of the appropriate professional indemnity insurance arrangements that are in force in relation to the practitioner’s practice of the profession. whether in a participating jurisdiction or elsewhere. in any profession in Australia (under the National Law. professional performance or health. 4. 8. A registered health practitioner must undertake the continuing professional development required by an approved registration standard for the health profession in which the practitioner is registered. A registered health practitioner must not. make sure that you have answered all of the relevant questions correctly and read the statements below. 3. Change in principal place of practice. Page 9 of 12 . sell. 5. (iii) the Secretary within the meaning of the National Health Act 1953 (Cth). The registered health practitioner must not. 6 or 8 below does not constitute an offence but may constitute behaviour for which health. A National Board may. A registered health practitioner must. performance or health proceedings whilst registered under the National Law. Notice of certain events 5. at any time by written notice given to a health practitioner registered by the Board. a corresponding prior Act or a law of a co-regulatory jurisdiction). undertakings or limitations in Australia (under the National Law or a corresponding prior Act) or overseas? 27. NO You must attach to this application details of any conduct.

regarding my practice as a health practitioner or otherwise regarding matters relevant to this application. Your registration fee depends on your principal place of practice. money order or bank draft must be in Australian currency. I confirm that I have read the privacy and confidentiality statement for this form. and • information will be extracted from this form and used for the purpose of criminal history checking. and • I am the person named in the attached documents. you must write: • your name • your date of birth. Mark one box below only Visa or MasterCard  Complete credit/debit card payment slip below Cash/EFTPOS (only available if paying in person) Cheque/Money order/Bank draft A receipt will be posted. money order or bank draft. On the back of the cheque. and findings of guilt for which no conviction was recorded.*APRO-7610* APRO-76 Consent I declare that: • the above statements. If your application is approved you will be registered for 12 months from the date of approval. I consent to the Board and AHPRA making enquiries of. and • your registration number (if applicable). I make this declaration in the knowledge that a false statement is grounds for the Board to refuse registration. and • failure to complete all relevant sections of this application and to enclose all supporting documentation may result in this application not being accepted. as applicants whose principal place of practice is New South Wales are entitled to a rebate from the NSW Government. Your required payment is detailed below: Use the table below to select your registration fee. Signature of applicant SIGN HERE Name of applicant Date D D / MM / Y Y Y Y SECTION H: Payment You are required to pay a registration fee. and exchanging information with. I undertake to comply with all relevant legislation and Board registration standards. This information may be used by Australian police services for law enforcement purposes including the investigation of any outstanding criminal offences. I understand that: • a complete criminal history. I authorise the Board to obtain my criminal history in Australia and overseas. I am aware that personal information that I provide may be given to a third party for regulatory purposes. or other country. 29. and the documents provided in support of this application. including resolved and unresolved charges. You must attach cheque or money order payable to the Australian Health Practitioner Regulation Agency. I acknowledge that: • the Board may validate documents provided in support of this application as evidence of my identity. Credit/Debit card payment slip – please fill out Amount payable Name on card $ Cardholder’s signature Visa or MasterCard number SIGN HERE Expiry date MM / Y Y Effective from: 9 September 2014 Page 10 of 12 . consistent with the National Law. Registration period The annual registration period for provisional psychologists is 12 months. the authorities of any Australian state or territory. drawn on an Australian bank. How are you paying your fees? Payment by cheque. codes and guidelines. Refund rules The registration fee will be refunded if the application is not approved. are true and correct. Registration fee: Amount payable: $ INSERT FEE = Registration fee $431 Registration fee for NSW registrants $330 $ INSERT FEE A pplicants must pay 100% of the stated fees at the time of submitting the application. will be released to the Board. spent convictions.

ahpra.au Sydney NSW 2001 Canberra ACT 2601 Melbourne VIC 3001 Brisbane QLD 4001 Adelaide SA 5001 Perth WA 6001 Hobart TAS 7001 Darwin NT 0801 Effective from: 9 September 2014 Page 11 of 12 .*APRO-7611* APRO-76 SECTION I: Checklist Have the following items been attached or arranged. cancellation.gov. your name and registration number are written on the back Please post this form with payment and required attachments to: AHPRA GPO Box 9958 IN YOUR CAPITAL CITY (refer below) You may contact AHPRA on 1300 419 495 or you can lodge an enquiry at www. undertakings. if required? Additional documentation Attached Question 1 Evidence of a change of name Question 3 Certified copies of all documents that provide sufficient evidence of your identity Question 8 Original academic transcripts for all your relevant qualifications must be sent directly to AHPRA by the issuing institution Question 9 Assessment of your qualifications that is completed by the Board-approved assessment body Question 10 A completed Supervised practice plan (4+2 internship) form Question 10 A copy of your position description(s) Question 11 Evidence of your current enrolment in an APAC-accredited Graduate Diploma of Professional Psychology requested from relevant authority Question 12 Evidence of current enrolment requested from relevant authority Question 13 Form AATP-76 – Application for approval of a transitional program Question 14 Signed and dated curriculum vitae outlining your practice history Question 15 Certificate of Registration Status or Certificate of Good Standing has been requested from relevant authority Question 15 A separate sheet with additional registration details Question 16 A separate sheet with an explanation of circumstances of your criminal history in Australia Question 17 A separate sheet with an explanation of circumstances of your criminal history overseas Question 19 A certified copy of the original evidence of having undertaken your secondary education and tertiary qualifications in English Question 20 Evidence of the successful completion of an approved English language test has been requested from relevant authority Question 21 Evidence that you have actively maintained employment using English as the primary language of practice Question 23 A separate sheet with your impairment details Question 24 A separate sheet with your current suspension or cancellation details Question 25 A separate sheet with you previous suspension. or limitations details Question 27 A separate sheet with your disqualification details Question 28 A separate sheet with your conduct. performance or health proceedings Payment Registration fee If paying by cheque/money order/bank draft. or refusal details Question 26 A separate sheet with your conditions.

gov. regulatory or policy development roles. Photocopies of previously certified documents will not be accepted. AHPRA will conduct a check on your behalf. The National Law requires you to declare any impairments at the time of application.au/Registration-Standards ENGLISH LANGUAGE SKILLS T o be eligible for registration you must be able to provide evidence of English language skills that meet the Board’s English language skills registration standard which can be found at www. or other purpose required by the National Law. and any other roles that impact on safe. The Board will decide whether a health practitioner’s criminal history is relevant to the practice of the profession. you must provide a certified copy of the original document and translation in accordance with AHPRA guidelines.psychologyboard. Copies of documents provided in support of an application.psychologyboard. view the Recency of practice registration standard and the Policy for recency of practice requirements online at www. Evidence must be a certified copy of one of the following documents: • Standard marriage certificate (ceremonial certificates will not be accepted). Additional guidance on remedial action to meet recency of practice requirements is included in the Policy for recency of practice requirements. at the time the application for renewal of registration is made. Effective from: 9 September 2014 Page 12 of 12 . advisory. scanned or emailed copies of certified documents will not be accepted. in which you use your skills and knowledge as a health practitioner in your profession.ahpra.gov. spent convictions legislation does not apply to criminal history disclosure requirements. Individuals who are currently enrolled in or have successfully completed a Board-approved sequence of study required for registration within the previous five years are exempt. If original documents are not in English. ‘I have sighted the original document and certify this to be a true copy of the original’ and signed by the authorised officer.gov. For more information.au/certify Practice means any role.gov.psychologyboard. or disorder (including substance abuse or dependence) that detrimentally affects or is likely to detrimentally affect your capacity to practise the profession. view the complete registration standard online at www. education. you must disclose your complete criminal history as detailed above.au/Registration-Standards IMPAIRMENT Impairment means a physical or mental impairment. effective delivery of services in the profession.g. date of certification. Faxed. and position number (if relevant) and have the stamp or seal of the authorised officer (if relevant) applied. or some alternative form of indemnity cover that complies with the Board’s standard.au/Registration-Standards RECENCY OF PRACTICE In accordance with the Recency of practice registration standard an individual must. For more information. CRIMINAL HISTORY PROFESSIONAL INDEMNITY INSURANCE (PII) You must have PII. Practitioners who do not meet the recency of practice requirements may be required to undertake remedial action in order to be eligible to renew their registration. research.ahpra. Under the National Law. must be certified as true copies of the original documents. For a list of people authorised to certify documents. at any time: • every conviction of a person for an offence • every plea of guilty or finding of guilt by a court of the person for an offence.gov. Therefore. Do not provide copies of a criminal history check. For more information.au/registration/registration-process • be initialled on every page by the authorised officer. view the full registration standard online at www. • Deed poll.au/certify • be annotated on the last page as appropriate e.au/Standards-and-Guidelines Criminal history includes the following. for all aspects of your practice. For more information. Each and every certified document must: • be in English. be able to demonstrate that he or she has practised unconditionally as a registered psychologist in the past five years. Certified copies will only be accepted in hard copy by mail or in person (not by fax. CHANGE OF NAME You must provide evidence of a change of name if you have ever been formally known by another name(s) or any of the documentation you are providing in support of your application is in another name(s). whether remunerated or not. and • every charge made against the person for an offence. If you have an impairment.you will need to confirm this with your employer. condition. working in management. irrespective of the time that has lapsed since the charge was laid or the finding of guilt was made. AHPRA’s guidelines for certifying documents can be found online at www.ahpra. disability. you will need to provide details of the impairment and how it is managed. which are available at www. and • list the name. • Change of name certificate. whether or not a conviction is recorded for the offence. visit www. and contact phone number.psychologyboard. administration.gov. whether in Australia or overseas. Initial registration and annual renewal of registration requires a declaration that you will be covered for all aspects of practice for the whole period of the registration. You may be covered by your Australian employer’s PII . email. It also includes using professional knowledge in a direct non-clinical relationship with clients. etc). Practice is not restricted to the provision of direct clinical care.*APRO-7612* APRO-76 Information and definitions CERTIFYING DOCUMENTS PRACTICE DO NOT send original documents unless specified.gov.