Nzsta Application For Qualifications Approval Of Overseas Qualifications printable pdf download

Nzsta Application For Qualifications Approval Of Overseas Qualifications

NZSTA Application for Qualifications Approval

of Overseas Qualifications

for overseas trained speech-language therapists who wish to apply for membership of NZSTA and

do not meet the criteria to apply under The Agreement for the Mutual Recognition of

Professional Association Credentials 2008

Personal Details:

Title _______

Surname _________________________ First Name ____________________

Mailing Address ___________________________________________________________________

_________________________________________________________________________________

Country __________________________________________

Post/ZIP code _______________

Phone Numbers (Home) ________________ (Work) __________________ (Mobile) ________________

E-mail ______________________________________________

Date of Birth

day

month

year

Any previous name (if changed) _____________________________________________________________

First language __________________________

Other languages ________________________________

Membership of Professional Association (please give details) ______________________________________

Employment:

Areas of clinical interest ___________________________________________________________________

Number of years of actual work experience in speech-language therapy/pathology ____________________

Referees - Names and contact details of two recent employers who may be contacted to verify work experience.

1. Name __________________________________

Position ________________________________

Organisation & City _____________________________________________________________________

E-mail _____________________________________ Telephone number _______________________

2. Name _____________________________________ Position ________________________________

Organisation & City _____________________________________________________________________

E-mail _____________________________________ Telephone number _______________________

Page 1 of 4 – Application for Qualifications Approval

1 October 2010

Nzsta Application For Qualifications Approval Of Overseas Qualifications