Application Form For Registration In The Register Of Medical Practitioners Form - 2015 Page 6

ADVERTISEMENT

NOTE:
8
IT IS IMPERATIVE THAT YOU ANSWER EACH OF THE FOLLOWING
QUESTIONS BY TICKING THE
.
APPROPRIATE BOX
.1
?
Y
*
N
Q
HAVE YOU EVER BEEN CONVICTED IN A COURT OF LAW
ES
O
(
)
INCLUDING A DRUNKEN DRIVING CHARGE
*I
,
F YES
PLEASE PROVIDE FULL PARTICULARS OF YOUR CONVICTION ON A SEPARATE PAGE AND
.
ATTACH
.2
D
Y
*
N
Q
O YOU NOW OR HAVE YOU EVER SUFFERED FROM A RELEVANT MEDICAL
ES
O
DISABILITY
THAT
MIGHT
AFFECT
YOUR
COMPETENCE
AS
A
MEDICAL
? [S
11
G
R
.]
PRACTITIONER
EE PARAGRAPH
OF THE
UIDE TO
EGISTRATION
*I
,
,
,
F YES
PLEASE PROVIDE FULL PARTICULARS
INCLUDING NAME
ADDRESS AND CONTACT DETAILS
(
)
8
OF YOUR TREATING DOCTOR
S
IN THE SPACE PROVIDED ON PAGE
AND PROVIDE A STATEMENT ON
.
A SEPARATE PAGE AND ATTACH
.3
H
:
Q
AVE YOU EVER BEEN TREATED FOR
(A)
?
Y
*
N
ALCOHOL DEPENDENCE
ES
O
(B)
?
Y
*
N
DRUG DEPENDENCE
ES
O
*I
,
,
,
F YES
PLEASE PROVIDE FULL PARTICULARS
INCLUDING NAME
ADDRESS AND CONTACT DETAILS
(
)
8
OF YOUR TREATING DOCTOR
S
IN THE SPACE PROVIDED ON PAGE
AND PROVIDE A STATEMENT ON
.
A SEPARATE PAGE AND ATTACH
.4
H
/
Y
*
N
Q
AVE YOU EVER BEEN REQUIRED TO UNDERGO REMEDIATION
RETRAINING
ES
O
/
FOLLOWING AN ASSESSMENT OF YOUR COMPETENCE
PERFORMANCE AS A
MEDICAL PRACTITIONER BY A REGISTRATION AUTHORITY OR OTHER BODY
?
RESPONSIBLE FOR CONDUCTING SUCH ASSESSMENTS
*I
,
,
F YES
PLEASE PROVIDE FULL PARTICULARS
INCLUDING THE NAME OF THE BODY WHICH
8
CONDUCTED THE ASSESSMENT IN THE SPACE PROVIDED ON PAGE
AND PROVIDE A STATEMENT ON A
.
SEPARATE PAGE AND ATTACH
.5
H
Y
*
N
Q
AS ANY REGISTRATION AUTHORITY EVER REFUSED TO GRANT YOU
ES
O
REGISTRATION TO ENGAGE IN THE PRACTICE OF MEDICINE AS A REGISTERED
?
MEDICAL PRACTITIONER
*I
,
,
,
F YES
PLEASE PROVIDE FULL PARTICULARS
INCLUDING THE REASONS FOR REFUSAL
IN A
.
STATEMENT ON A SEPARATE PAGE AND ATTACH
.6
/
?
Y
*
N
Q
HAVE YOU EVER BEEN DEPORTED AND
OR EXCLUDED FROM ANY COUNTRY
ES
O
*I
,
.
F YES
PLEASE PROVIDE FULL PARTICULARS IN A STATEMENT ON A SEPARATE PAGE AND ATTACH
HAVE YOU EVER PRACTISED MEDICINE WITHOUT REQUIRING REGISTRATION I.E.
Q.7
YES*
NO
HAVE YOU PRACTISED MEDICINE IN A COUNTRY FROM WHERE YOU CANNOT
PROVIDE A CERTIFICATE OF GOOD STANDING ISSUED BY THE RELEVANT
REGISTRATION AUTHORITY IN THAT COUNTRY?
If YES, PLEASE PROVIDE FULL PARTICULARS, INCLUDING NAME, ADDRESS AND CONTACT DETAILS OF
YOUR EMPLOYER IN THE SPACE PROIVED ON PAGE 8 AND PROVIDE A STATEMENT AS TO WHY THAT
POST(S) DID NOT REQUIRE FORMAL REGISTRATION IN THAT COUNTRY. FOR MULTIPLE POSTS PLEASE
PROVIDE THE ABOVE DETAILS FOR EACH POST
.8
Y
*
N
Q
HAVE YOU EVER BEEN THE SUBJECT OF DISCIPLINARY PROCEEDINGS OR A
ES
O
COMPLAINT OR ARE ANY PROCEEDINGS OR COMPLAINTS IN PROGRESS OR
PENDING NOW BY AN AUTHORITY WITH WHOM YOU ARE OR WERE REGISTERED
?
/
OR EMPLOYED AS A MEDICAL PRACTITIONER
AND
OR HAS YOUR NAME EVER
/
/
BEEN ERASED
SUSPENDED
REMOVED FROM A REGISTER MAINTAINED BY ANY
/
?
REGISTRATION AUTHORITY WITH WHOM YOU ARE
WERE REGISTERED
[
/
-
.]
INCLUDE ANY ERASURE
REMOVAL DUE TO NON
PAYMENT OF FEES
*IMPORTANT: I
“
”
.8,
F YOU ANSWERED
YES
TO Q
PLEASE PROVIDE FULL PARTICULARS
AND
.8.
,
.8.
.8.
.
ON A SEPARATE PAGE
ANSWER Q
A
Q
B AND Q
C OVERLEAF
Q.8.A.
,
/
:
NAME
ADDRESS AND CONTACT DETAILS OF THE REGISTRATION AUTHORITY
EMPLOYER
NAME:
VERSION 8.0 - T
2015
HIS FORM WAS LAST UPDATED IN AUGUST
Page 6 of 16
-
-
PLEASE ENSURE YOU COMPLETE THE MOST UP
TO
DATE FORM AVAILABLE ON OUR WEBSITE

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Applications For Remarriage In The Diocese Of South Carolina Applications For Remarriage In The Diocese Of South Carolina Business
Application For Membership In The Society Of Commercial Realtors Application For Membership In The Society Of Commercial Realtors Legal
Form Bia-4432 - Verification Of Indian Preference For Employment In The Bureau Of Indian Affairs And The Indian Health Service Form Bia-4432 - Verification Of Indian Preference For Employment In The Bureau Of Indian Affairs And The Indian Health Service Legal
Instructions For Deposit In The Nature Of A Cash Bond Form Apl-004 Instructions For Deposit In The Nature Of A Cash Bond Form Apl-004 Financial
Application By A Foreign Registered Limited Liability Partnership For A Certificate Of Authority To Transact Business In The State Of South Carolina Application By A Foreign Registered Limited Liability Partnership For A Certificate Of Authority To Transact Business In The State Of South Carolina Legal
Form Rpg-a1-97- Application For Registration Mississippi State Board Of Registered Professional Geologists Form Rpg-a1-97- Application For Registration Mississippi State Board Of Registered Professional Geologists Life
Form 31 - Application For Transfer Of Ownership In The Name Of The Person Succeeding Of The Possession Of The Vehicle Form 31 - Application For Transfer Of Ownership In The Name Of The Person Succeeding Of The Possession Of The Vehicle Legal
Form Met 2 Adj - Application For Refund Of Maryland Estate Tax To Be Paid Directly To The Register Of Wills Form Met 2 Adj - Application For Refund Of Maryland Estate Tax To Be Paid Directly To The Register Of Wills Financial
Form Met 2 Adj - Application For Refund Of Maryland Estate Tax To Be Paid Directly To The Register Of Wills Tax-general Article, Section 13-906(b) Form Met 2 Adj - Application For Refund Of Maryland Estate Tax To Be Paid Directly To The Register Of Wills Tax-general Article, Section 13-906(b) Financial
Form Met 2 Adj - Application For Refund Of Maryland Estate Tax To Be Paid Directly To The Register Of Wills Form Met 2 Adj - Application For Refund Of Maryland Estate Tax To Be Paid Directly To The Register Of Wills Financial

Related Categories

Parent category: Business
Download
Go
Page of 16