Deferral of Internship Form

*Deferral of Internship – Category one candidates only* Deferral is for up to 12 months. Any further period of deferral requires repeat notification to the PMCV and discussion with the PMCV Medical Director. Any person considering deferral of internship should read the PMCV Policy – Deferral of Internship. Candidates MUST submit this form to PMCV by 5pm AEST, Wednesday 3 July 2023.

Section A – Candidate Details

Full Name(Required)

PMCV Candidate ID (if applicable)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

University(Required)

Section B – Notification of Deferral

This is my first / second deferral of internship (please select)(Required)

First Deferral

Second Deferral

Section C – Reason for Deferral

Please indicate reason for deferral:(Required)

Section D – Declaration

Please indicate that you have read and agree to comply with the Policy:(Required)

Yes

Name(Required)

Prefix First Last

Date(Required)

Our Organisation

Our People

Resources & Guidelines

Accreditation Resources

Our Organisation

Our People

Resources & Guidelines

Accreditation Resources

Deferral of Internship Form

Section A – Candidate Details

Section B – Notification of Deferral

Section C – Reason for Deferral

Section D – Declaration

Our Organisation

Our People

Resources & Guidelines

Accreditation Resources

Deferral of Internship Form

Section A – Candidate Details

Section B – Notification of Deferral

Section C – Reason for Deferral

Section D – Declaration

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