Application Form For Registration In The Register Of Medical Practitioners Form - 2015 Page 4
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167. R
D
EGISTRATION
ETAILS
,
HAVE YOU APPLIED TO THIS MEDICAL COUNCIL BEFORE FOR ANY TYPE OF REGISTRATION
(Please tick appropriate box/es)
YES
NO
/
?
HAVE YOU EVER BEEN GRANTED
HELD REGISTRATION IN THE REPUBLIC OF IRELAND
Yes
No
(Please tick appropriate box)
:
NOTE
YOU SHOULD COMPLETE THE RESTOREAPP FORM IF YOU HAVE PREVIOUSLY BEEN REGISTERED IN THE TRAINEE
16/03/09. I
SPECIALIST OR GENERAL DIVISIONS OF THE REGISTER ON OR AFTER
F YOU WERE LAST REGISTERED PRIOR
16/03/09
.
TO
THIS IS THE CORRECT FORM
+˚
/
:
REGISTRATION
REFERENCE NUMBER QUOTED TO YOU IN PREVIOUS CORRESPONDENCE
PLEASE LIST ALL THE AUTHORITIES WITH WHICH YOU HAVE EVER BEEN REGISTERED FOR THE
PURPOSE
OF
ENGAGING
IN
THE
PRACTICE
OF
MEDICINE
AS
A
REGISTERED
MEDICAL
:
PRACTITIONER
#1.
:
AUTHORITY
NAME AND ADDRESS OF REGISTRATION AUTHORITY
Name:
Address:
R
D
D
M
M
Y
Y
Y
Y
T
:
D
D
M
M
Y
Y
Y
Y
EGISTERED FROM
O
:
:
TYPE OF REGISTRATION HELD
REGISTRATION NUMBER
#2.
:
AUTHORITY
NAME AND ADDRESS OF REGISTRATION AUTHORITY
Name:
Address:
R
D
D
M
M
Y
Y
Y
Y
T
:
D
D
M
M
Y
Y
Y
Y
EGISTERED FROM
O
:
:
TYPE OF REGISTRATION HELD
REGISTRATION NUMBER
#3.
:
AUTHORITY
NAME AND ADDRESS OF REGISTRATION AUTHORITY
Name:
Address:
R
D
D
M
M
Y
Y
Y
Y
T
:
D
D
M
M
Y
Y
Y
Y
EGISTERED FROM
O
:
:
TYPE OF REGISTRATION HELD
REGISTRATION NUMBER
NOTE:
,
IF REGISTERED WITH ANY ADDITIONAL AUTHORITIES
PLEASE CONTINUE ON A SEPARATE PAGE AND ATTACH
IMPORTANT PLEASE READ BEFORE CONTINUING
LIST ALL REGISTRATION AUTHORITIES WITH WHOM YOU HAVE HELD REGISTRATION IN
THE LAST FIVE YEARS EVEN IF YOU HAVE NOT PRACTISED MEDICINE IN THAT COUNTRY.
8. E
P
-R
E
S
(PRES)
XEMPTION FROM THE
RE
EGISTRATION
XAMINATION
YSTEM
VERSION 8.0 - T
2015
HIS FORM WAS LAST UPDATED IN AUGUST
Page 4 of 16
-
-
PLEASE ENSURE YOU COMPLETE THE MOST UP
TO
DATE FORM AVAILABLE ON OUR WEBSITE
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