Application Form For Registration In The Register Of Medical Practitioners Form - 2015 Page 3

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5. P
Q
ROFESSIONAL
UALIFICATIONS
+˚
(
) (
):
PRIMARY MEDICAL QUALIFICATION
S
ABBREVIATIONS
NOTE: T
,
.
.
HE QUALIFICATION TO BE ENTERED IS THE MEDICAL QUALIFICATION
ON WHICH YOUR APPLICATION IS BASED
E
G
,
,
MBBS
MD
ETC
EXAMPLE:
M
B
B
C
h
N
U
I
+˚
:
DATE OF CONFERRAL
D
D
M
M
Y
Y
Y
Y
…
DATE YOUR UNDERGRADUATE MEDICAL COURSE
:
M
M
Y
Y
Y
Y
˚
:
M
M
Y
Y
Y
Y
COMMENCED
ENDED
:
LANGUAGE OF INSTRUCTION DURING YOUR UNDERGRADUATE COURSE
˚
:
COUNTRY IN WHICH YOU QUALIFIED
˚
: (
)
NAME AND ADDRESS OF MEDICAL SCHOOL
PLEASE INCLUDE INTERNATIONAL CODES
Name of Medical School:
Address:
: (
)
CONTACT DETAILS OF MEDICAL SCHOOL
PLEASE INCLUDE INTERNATIONAL CODES
Email
address:
Phone:
Fax:
Name of University (if different from Medical School):
(
)
:
NAME AND ADDRESS OF HOSPITAL
S
IN WHICH YOU COMPLETED YOUR INTERNSHIP TRAINING
…
DATE YOUR INTERNSHIP TRAINING
:
M
M
Y
Y
Y
Y
˚
:
M
M
Y
Y
Y
Y
COMMENCED
ENDED
:
LANGUAGE OF INSTRUCTION DURING YOUR INTERNSHIP TRAINING
6. P
S
T
OSTGRADUATE
PECIALIST
RAINING
?
ARE YOU REGISTERED WITH A POSTGRADUATE TRAINING BODY IN IRELAND
Yes
No
(Please tick appropriate box)
,
A
:
IF YES
PLEASE PROVIDE NAME AND
DDRESS OF THE TRAINING BODY
/
?
HAVE YOU BEEN OFFERED A PLACE
ACCEPTED ON A POSTGRADUATE TRAINING PROGRAMME
Yes
No
(Please tick appropriate box)
VERSION 8.0 - T
2015
HIS FORM WAS LAST UPDATED IN AUGUST
Page 3 of 16
-
-
PLEASE ENSURE YOU COMPLETE THE MOST UP
TO
DATE FORM AVAILABLE ON OUR WEBSITE

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