Health (Notifications by Midwives) Regulations 1994


11/Jun/2004 - Current (at 31 Dec 2005)
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    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.: .......................................................................

Nurses Board Registration Nos. General: ........ Midwifery: .............................

Date of Initial Registrations General: ........ Midwifery: .............................


...............................................
Signature
    ...............................................
    Date
    *Delete if not applicable

    FORM 2
    [reg. 4]


    Note: This is not an authorised version. The only authorised version is the hardcopy (printed) version published under authority of the Government Printer, available from the State Law Publisher, 10 William St Perth W.A. 6000.