AF2009-207	  Health Act 1993 s 105

AUTHORISATION OF REPRESENTATIVE

I,   								  (name of VMO) 

of  								  (address of VMO)

authorise

								  (full name of entity)

								  (address of entity)

								  (ABN of entity) 

to act as my authorised representative in collective negotiations with the Territory under s 103 of the Health Act 1993

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 104 of the Health Act 1993 before being able to negotiate with the Territory on my behalf.

Signed:    							  (signature of VMO)

Witness:  							  (signature of witness)

Name:     							  (print name of witness)

Date: