APPLICATION FOR HEALTH PROFESSIONAL LICENSURE

Transcription

1 APPLICATION FOR HEALTH PROFESSIONAL LICENSURE Passport Size Photograph Please complete this application on the computer then print and sign. Hand-written applications will not be accepted. Section 1: Application Details Have you ever applied to the Dubai Health Authority (DHA) for licensure? I am applying for: (please tick the appropriate category) I am applying for the professional license of: Employing Facility No Please give details Physician or Dentist Nurse & Midwife Yes Allied Health Complementary Alternative Medicine (CAM) For Official Use Only Approved Title : Section 2: Personal Details (Please enter all details as per passport) First name (given) Middle name Last name (family/surname) Maiden name (if applicable) DOB: Passport Number Date of Issue Place of Birth Nationality Date of Expiry UAE National ID No Yes Number (if applicable) in Home Country: in UAE: (if different from above) Tel. (residence) Tel. (business) Tel. (local UAE contact no) regulation@dha.gov.ae Page 1 of 7

2 Section 3: Education Information- 1 Name as per Certificate University/Institution Name (If certificate name is different than name as per passport, then please submit the relevant name change document) College Name University. City University Country Qualification Attained (e.g. Doctor of Medicine) Major Subject Student Identity / Roll No. Attendance Period Qualification Conferred Date Education Information 2 (When applicable) 12/02/2011 Area. Minor Subject To Name as per Certificate University/Institution Name (If certificate name is different than name as per passport, then please submit the relevant name change document) College Name University. City University Country Qualification Attained (e.g. Doctor of Medicine) Major Subject Student Identity / Roll No. Attendance Period Qualification Conferred Date Area. Minor Subject To Note: If you have more certificates, add them in a separate page. regulation@dha.gov.ae Page 2 of 7

3 Section 4: License Information Name as per License Issuing Authority Name City Issuing Authority Country Area. License Attained License Type License No. Issue Period To License Conferred Date Section 5: Experience Details Please provide FULL details of employer for last 5 years starting in order from latest to the previous employer First Employer Details Second Employer Details To To regulation@dha.gov.ae Page 3 of 7

4 Third Employer Details Fourth Employer Details Fifth Employer Details To To To Page 4 of 7

5 Section 6: Declaration I here by attest that the following questions have been answered to the best of my knowledge: 1. Health status: Do you have any physical, mental or emotional condition which may impair your ability to render professional services which are the subject of this application? Yes No 2. License: Has your professional license in any country ever been suspended, revoked or placed on a conditional status? Yes No 3. License: Are there any formal investigation pending against you at this time? Yes No 4. Hospital Sanctions: Have you ever voluntarily surrendered or diminished your clinical privileges pending an investigation that may have lead to censure, restriction, suspension or revocation of such privileges? Yes No 5. Criminal Offences: Have you ever been convicted of a felony or involved in charges relating to moral or ethical turpitude? Yes No 6. Disciplinary Actions: Have you ever been the subject of disciplinary proceedings by any professional association or organisation Yes No 7. Malpractice Insurance Coverage: Has there ever been any malpractice claims or lawsuits made against you alleging negligence or a treatment failure which has been pending, open or closed during any of your health professional practices? Yes No If you answered yes to any of the above questions; please explain: I hereby affirm by my signature, that the information I have completed under penalty of perjury is true and correct. Should I furnish any false information in this application I hereby agree that such an act shall constitute cause for the denial, or suspension or revocation of my license to practice? Signature: Date:18/10/ regulation@dha.gov.ae Page 5 of 7

6 Letter of Authorization I hereby authorize the Dubai Health Authority or DataFlow FZ LLC, its authorized affiliates, agents and subsidiaries, acting on its behalf to verify information, documentation and back ground verification presented on my application form including but not limiting to education, employment and licenses. I hereby grant the authority for the bearer of this letter, with immediate effect, to release all necessary information to the Dubai Health Authority or DataFlow FZ LLC, its authorized affiliates, agents and subsidiaries. This information / documentation may contain but is not limited to grades, dates of attendance, grade point average, degree / diploma certification, employment title, employment tenure, license attained, status of the license, place of issue and any other information deemed necessary to conduct the verification of the information / documentation provided. I hereby release all persons or entities requesting or supplying such information from any liability arising from such disclosure. I am willing that a photocopy of this authorization be accepted with the same authority as the original. I further understand and acknowledge that this Information Release Form will remain valid for a period of two years following its completion. I confirm that all my certificates are affiliated and accredited from the issuing country Personal Details: (in BLOCK letters) Full Name : (Last/Surname) (First Name) (Middle Name) Passport /Identity Card Number: Signature Date regulation@dha.gov.ae Page 6 of 7

7 Applicant Name: Document / Information Checklist (To be filled by the applicant) The following documents are mandatory. Please note that the request will not be processed if this information / documents are not provided. (Please provide clear and legible copies) A Applicable to all 1 Application form duly filled in its entirety 2 Valid Passport Copies 3 Degree certificate copies (copy of original certificate(s)& translated copy) 4 Experience letters from previous employers for the last five years 5 Medical / Nursing license copy (front and back) 6 Valid Good Standing Certificate or equivalent 7 Payment receipt copy B Applicable in special circumstances 1 Copy of the surgical log book (for surgeons only) 2 Mark sheet for the final year (all year mark sheets for applicants who have studied in India) 3 Copy of the backside on the degree certificate ( for applicants having Afghanistan, Egyptian & Pakistani degrees/certificates) 4 Certificate of Authenticity and Verification (CAV) for applicants who have studied in Philippines 5 Name change certificate, if applicable (Marriage certificate, affidavit, any legal document, etc.) Decision: Approved As Pending As Rejected Credentialing: For Official Use Only Notes: Name Signature Date Primary Source Verification (PSV): Basic Degree Additional Degree Applicant informed Professional license History Name Signature Date regulation@dha.gov.ae Page 7 of 7