Application Form For Registration In The Register Of Medical Practitioners Form - 2015

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GENERICAPPFORM
:
REFERENCE NUMBER
Kingram
House,
Kingram
Place,
Dublin
D02
XY88
Ireland.
Telephone: +353-1-4983100
Facsimile: +353-1-4983102
Email:
Website:
APPLICATION FORM FOR REGISTRATION IN THE REGISTER OF MEDICAL PRACTITIONERS
13
(
)
ALL
PARTS OF THIS APPLICATION FORM MUST BE COMPLETED INCLUDING THE CHECKLIST
S
1. W
C
?
HICH
ATEGORY
P
C
:
LEASE TICK THE MOST APPROPRIATE
ATEGORY FOR YOUR APPLICATION BELOW
CATEGORY 1:
Graduate of Medical School in Ireland (UCD, UCC, NUIG, TCD, RCSI
or UL). Please see website for current fees.
Please affix firmly
CATEGORY 2:
EU/EEA or Swiss citizen qualified in an EU/EEA member state or in
a recent
Switzerland. Please see website for current fees.
passport-size
CATEGORY 3:
Non-EU citizen who qualified in an EU/EEA member state or in
colour photograph
Switzerland. Please see website for current fees.
of yourself
CATEGORY 4:
Graduate of a medical school in a third country (outside EU/EEA/
HERE
Switzerland) and qualification listed in Avicenna Please see website for current
fees.
st
Note:
From 1
September 2015, in advance to making an for application,
Category 4 applicants are required to have the required medical education
credentials, as outlined in Item 11, primary-source verified through the
Electronic Portfolio of International Credentials (EPIC). For more information
on EPIC and to begin the verification process, visit
N
:
1
30
.
ST
TH
OTES
THE REGISTRATION YEAR RUNS FROM
JULY TO
JUNE EACH YEAR
IF A DOCTOR IS REGISTERED DURING THE
,
1
.
ST
REGISTRATION YEAR
A RETENTION FEE IS PAYABLE ON THE FOLLOWING
JULY
+
,
+
.
IF REGISTRATION IS GRANTED
ITEMS MARKED
WILL APPEAR ON THE REGISTER OF MEDICAL PRACTITIONERS
˚
,
˚
,
/
IF REGISTRATION IS GRANTED
ITEMS MARKED
MAY BE SHARED WITH RELEVANT THIRD PARTIES
EG TRAINING BODIES
HSE
2. EPIC ID (CATEGORY 4 APPLICANTS ONLY):
3. W
D
?
HICH
IVISION
H
?
AVE YOU COMPLETED SPECIALIST TRAINING
Yes
No
(Please tick appropriate box)
,
.
IF YOU ANSWER YES
THIS IS THE WRONG FORM
PLEASE COMPLETE THE SPECIALIST APPLICATION
.
FORM
A
? (
)
RE YOU SEEKING REGISTRATION IN TRAINING POSTS
SPECIALIST TRAINING
Yes
No
(Please tick appropriate box)
,
4
IF YES
CATEGORY
APPLICANTS PLEASE CHECK
YOUR ELIGIBILITY FOR TRAINEE SPECIALIST
. I
,
-
REGISTRATION BEFORE SUBMITTING
F NO
ALL APPLICANTS
YOUR APPLICATION WILL BE CONSIDERED
.
FOR REGISTRATION IN THE GENERAL DIVISION
4. P
D
ERSONAL
ETAILS
Professor
Dr
Mr
Ms
+
:
˚TITLE
(please circle/ tick appropriate box)
PLEASE TICK THE APPROPRIATE BOX BELOW TO INDICATE WHICH SURNAME YOU WISH TO HAVE ENTERED ON THE
R
:
EGISTER
+
/
:
˚SURNAME ON YOUR DEGREE
DIPLOMA
+
:
˚CURRENT SURNAME IF DIFFERENT TO ABOVE

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