Application Form For Registration In The Register Of Medical Practitioners Form - 2015 Page 15
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16Please note that the application fee is non-refundable. Please consult our website for
the most up-to-date information regarding application fees at:
https://
Method of Payments:
Payments may be made to the Medical Council by Bank Draft or Credit / Laser Card.
1. By Bank Draft
Bank drafts are acceptable provided:
(a) they are in Euro and are payable at an Irish Bank in Ireland. (If they are in Euro
but payable at a foreign bank these will be returned as they will incur bank charges
which may differ from day to day.) OR
(b) they are acceptable in Sterling payable at a British Bank in the U.K. OR
(c) they are acceptable in U.S. dollars payable at an American Bank in the U.S.
2. Credit / Laser Cards
Payments may be made by Visa or Mastercard or by Lasercard by completing the form
below.
An additional fee of 2.02% will apply to all VISA and MASTERCARD payments and a fee
of €0.25 for all LASERCARD transactions. If you require any assistance regarding the
above, please contact the Council's Finance section at +353-1-4983100.
PLEASE COMPLETE THIS FORM IF PAYING BY CREDIT / LASER CARD
(
F
S
.)
THIS PAGE WILL BE DETACHED AND SENT TO OUR
INANCE
ECTION WHEN YOUR COMPLETE APPLICATION IS RECEIVED
Doctor’s Name:
Registration Number (if known):
CREDIT
CARD
Exp
M
M
Y
Y
NUMBER
Date
CVV NO.
VISA
MASTERCARD
(last 3 digits on back)
LASERCARD
Exp
M
M
Y
Y
NUMBER
Date
Name of card holder:
Address of card holder:
Signature:
Date:
A
:
MOUNT TO BE DEBITED
(An additional fee of 2.02% will apply to all VISA/MASTERCARD payments and
€
€0.25 for all LASER transactions).
REASON FOR PAYMENT: DOCUMENT EXAMINATION FEE (LEVEL 1 ASSESSMENT)
Office Use Only:
PLEASE COMPLETE THIS FORM IF YOU WISH TO AUTHORISE THE MEDICAL COUNCIL TO
TAKE A FURTHER PAYMENT BY CREDIT / LASER CARD FOR REGISTRATION (IF
GRANTED)
Doctor’s Name:
VERSION 8.0 - T
2015
HIS FORM WAS LAST UPDATED IN AUGUST
Page 15 of 16
-
-
PLEASE ENSURE YOU COMPLETE THE MOST UP
TO
DATE FORM AVAILABLE ON OUR WEBSITE
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