Step 1 of 2 50% Practitioner InformationTitle*Name* First Last Home Address* Street Address Address Line 2 City State Postcode Phone Number*ABNWebsite Email* Proposed Activities*Note: Advertising will be strictly restricted to you principal modality under which this approval is given. Please supply all proposed advertising for approval. Attachments Required*Please Supply 1. Copy of certification of qualification including First Aid Certificate 2. Copy of current insurance policy 3. Copy of advertising: Business cards, etc Drop files here or Accepted file types: pdf, png, jpg. Practitioner Agreement I the undersigned, declare that the information given on this application is accurate and complete. I also agree to accept and abide by the Practitioner Policy Information, Terms and Conditions as detailed in the following pages. Practitioners are required to have and provide us a copy of their up to date indemnity insurance each year. It is the practitioner’s responsibility to keep their legal requirements for their practice. Signature*
