Form 18 - Application For Restoration Of Name To The Register In Terms Of Section 19(5) Of The Health Professions Act, 1974 (Act No. 56 Of 1974) - Health Professions Council Of South Africa

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APPLICATION FOR RESTORATION OF NAME TO THE
REGISTER IN TERMS OF SECTION 19(5) OF THE HEALTH
PROFESSIONS ACT, 1974 (ACT No. 56 OF 1974)
Form 18
NB: AN INCOMPLETE FORM WILL DELAY REGISTRATION
FOR
Please PRINT and return the FORM to:
OFFICE
The Registrar, PO Box 205, Pretoria 0001
USE ONLY
553 Vermeulen Street, Arcadia, Pretoria 0083
A.
PERSONAL PARTICULARS
Received on
HPCSA Registration Number:
……………………………………..
Amount
I, (Dr, Mr, Mrs, Miss)
Surname:
……………………………………..
Maiden name (if applicable):
Receipt No.
First names:
Identity No.:
……………………………………..
Postal address:
Date restored:
Postal code:
……………………………………..
Residential address:
CAPTURED
Postal code:
……………………………………..
DATE
Tel (H):
(W):
…………………………………….
Cell:
Fax:
VERIFIED
Email:
……………………………………..
* Marital Status:
Divorced
Married
Single
Gender:
Male
Female
DATE
* Race:
Asian
African
Coloured
White
Country of origin:
……………………………………..
Bank Details:
I request that my name be restored to the register of
for the Republic of South Africa
and hereby make oath and declare that I was registered as a
with the
HPCSA
registration number
My name was erased from the register under Section 19 of the Act.
Bank:
ABSA
I also delcare that I have never been convicted of any criminal offence or been debarred from practice by reason of
Branch:
unprofessional conduct in any country and that, to the best of my knowledge and belief, no proceedings involving or
Arcadia
likely to involve a charge of offence or misconduct is pending against me in any country at present.**
Branch code:
334945
Acc. No.
0610000169
SIGNATURE:
DATE:
PRACTITIONER
ORIGINAL OFFICIAL STAMP OF
COMMISSIONER OF OATHS
SIGNATURE
DATE
TO BE COMPLETED BY COMMISSIONER OF OATHS
** If you are unable to make the declaration in this paragraph, the Council requires full
particulars of the reason for your inability to do so in order to consider the application.
B.
The following is submitted in support of my application:
Please fax your
application
1.
The amount of
in respect of my application for restoration.
form and proof
of payment to
2.
A copy of my marriage certificate (should you wish to register in your married surname).
(012) 328 5120
* Please complete for statistical purposes.
NB: Please note that the Council, in the normal course of its duties, reserves the right to divulge information in
your personal file to other parties.
GA/05-01-2011

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