Fields on page 1
for a new APA
to renew an existing APA
to amend an existing APA
APA number
Authority name
Registered address
Registered address
1.App Add3
Postcode
Postal address (if different to above)
Postal address (if different to above)
1.App CoroAdd3
Postcode
Fields on page 2
Dr
Mr
Mrs
Miss
Ms
Mx
Other
Dr Mr Mrs Miss Ms Mx Other Authorised representative’s full name
Position held
PRODA Registration Authority (RA) number
Daytime phone number (including area code)
Mobile phone number
This is the email address we will use to notify you of the outcome of your application.
Dr
Mr
Mrs
Miss
Ms
Mx
Other
Dr Mr Mrs Miss Ms Mx Other Authorised representative’s full name
Position held
PRODA RA number
Daytime phone number (including area code)
Mobile phone number
Email
Australian Business
Business Number
Number (ABN)
(ABN)
Registered trading name if any (must be owned by the applicant)
Date trading name
trading name
name registration expires (DD
Individual
Partnership
Company
Government agency or public body
Dr
Mr
Mrs
Miss
Ms
Mx
Other
Family name
First given name
Fields on page 3
Full name of individual or company
1.Part PerCent1
Percentage share of Australian Business
share of partnership Business Number
of partnership Number (ABN) if
(ABN) if applicable
Australian Company
Company Number (ACN) if
Number (ACN) if applicable
Full name of individual or company
Percentage share of partnership
Percentage share of Australian Business
share of partnership Business Number
of partnership Number (ABN) if
(ABN) if applicable
Australian Company
Company Number (ACN) if
Number (ACN) if applicable
Full name of individual or company
1.Part PerCent3
Percentage share of Australian Business
share of partnership Business Number
of partnership Number (ABN) if applicable
(ABN) if applicable
Australian Company
Company Number (ACN) if
Number (ACN) if applicable
Full name of individual or company
Percentage share of partnership
Percentage share of Australian Business
share of partnership Business Number
of partnership Number (ABN) if
(ABN) if applicable
Australian Company
Company Number (ACN) if
Number (ACN) if applicable
Registered business name
Australian Company
Company Number (ACN)
Number (ACN)
1.
2.
3.
4.
5.
Full name
Approximate percentage of
Full name
Approximate percentage of
Full name
Approximate percentage of
Full name
Approximate percentage of
Full name
Approximate percentage of
Fields on page 4
Government agency or public body registered business name
Australian Business
Business Number
Number (ABN) if applicable
(ABN) if applicable
Full name
Position held
Full name
Position held
Full name
Position held
Full name
Position held
Full name
Position held
Full name
Position held
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
If you have answered ‘Yes’ to any of questions (a) to (f) at question 19, give details of name, company name and provider number
Provide any additional information to support this application
Fields on page 11
I (or we) (full name of pathology authority as detailed on page 1 in block letters)
Full name
Position held
Full address
Full address
1.App DecAdd3 1
Postcode
Signature
Date (DD MM YYYY)
(DD MM YYYY)
YYYY)
Full name
Position held
Full address
Full address
1.App DecAdd3 2
Postcode
Signature
Date (DD MM YYYY)
(DD MM YYYY)
YYYY)
I (full name of witness in block letters)
of (full address)
of (full address)
1.Wit Add3
Postcode
Date (DD MM YYYY)
(DD MM YYYY)
YYYY)
Fields on page 12
I (or we) (full name of pathology authority as detailed on page 1 in block letters)
Partnership signatory 1 Full name (block letters)
Company name (if applicable)
Australian Business
Business Number
Number (ABN) if
(ABN) if applicable
Australian Company
Company Number (ACN) if
Number (ACN) if applicable
Full address
Full address
1.Part DecAdd3 1
Postcode
Signature
Date (DD MM YYYY)
(DD MM YYYY)
YYYY)
Full name (block letters)
Company name (if applicable)
Australian Business
Business Number
Number (ABN) if
(ABN) if applicable
Australian Company
Company Number (ACN) if
Number (ACN) if applicable
Full address
Full address
give this undertaking recorded in this Schedule to the Minister.
Postcode
Signature
Date (DD MM YYYY)
(DD MM YYYY)
YYYY)
I (full name of witness in block letters)
of (full address)
of (full address)
1.Part Wit Add3
Postcode
Date (DD MM YYYY)
(DD MM YYYY)
YYYY)
