Australian Capital Territory

Health (Visiting Medical Officer Authorised Representative Form) Approval 2003 (No 1)*

Approved form AF2003—25

Made under the 

Health Act 1993, s 37A Form for Authorisation of a Representative.

I approve the attached form for the purpose of a visiting medical officer (VMO) authorising a representative under s33F of the Health Act 1993. 

Katy Gallagher MLA
Acting Minister for Health
1 October 2003

AF2003-25  Health Act 1993 s 33F

FORM OF AUTHORISATION under s33F

I,						(name and address of VMO) authorise

						(full name, address and ABN of entity) 

to act as my authorised representative in negotiations with the Territory under s33D of the Act.

I am a visiting medical officer and I consider that I belong to the following category (select one category only):

•	physician;

•	surgeon;

•	obstetrician and/or gynaecologist

•	anaesthetist;

•	general practitioner or other doctor or dentist.

I understand that my nominated representative must be approved as a negotiating agent under section 33E of the Health Act 1993 before being able to negotiate with the Territory on my behalf.

Signed:					(VMO)

Witness:					(signature of witness)

Name:						(print name of witness)

Date: