1. MAIN APPLICANT DETAILS Applicants Full name (as it appears in passport):

Size: px
Start display at page:

Download "1. MAIN APPLICANT DETAILS Applicants Full name (as it appears in passport):"

Transcription

1 Tel : info@nhra.bh Website : P.O. Box : 11464, Manama Kingdom of Bahrain For office use: application number: APPLICATION FOR AN AMBULATORY CARE FACILITY LICENSE KINGDOM OF BAHRAIN IMPORTANT: Please follow these instructions completely. Failure to submit the necessary items/information will delay the processing of your application. You must complete and submit all of the requested information. Please tick the relevant box: New Facility Complete all sections Renewal / Reinstatement* Complete sections 1 to 6 Change of Ownership Complete sections 1, 2, 3 and 6 Change of location Complete sections 1,2 and 6 Change of Facility Name Complete sections 1, 2 and 6 Change of Person in Charge Complete sections 1,2, 4 and 6 Change in Operational Function Complete sections 1,2, 5 and 6 Temporary Closure Complete section 1,2 and 5 *If reinstatement, due to: Lapse of license or Suspension or Revocation of a license 1. MAIN APPLICANT DETAILS Applicants Full name (as it appears in passport): Previous name (if different from above): Address: Telephone Nos. (Mobile): Fax No.: CPR No.: of Birth: DD / MM / YYYY (Business): address: Passport No.: Country of Issue: Gender (please tick): Male Female Nationality: License No;

2 2. FACILITY DETAILS Current Name of Facility: Name Change: Address of Facility: Is this a changed location: If Yes, Previous location: Is a current ambulatory care facility license held: Is there a current MOIC Commercial license: Premises Leased/Rented Address: NHRA License number: MOIC Commercial Premises Owned Contact No: Name of lessor/renter or owner if different from name of application: A COPY OF THE LEASE AGREEMENT MUST ACCOMPANY THIS APPLICATION 3. STAKEHOLDERS OWNERSHIP TYPE check one: Corporation Partnership Individual Other LIST OF OWNERS/OFFICERS AND RESIDENCE ADDRESSES BELOW, OR LIST IS ATTACHED

3 4. PROFESSIONAL STAFF LIST OF DOCTORS PRACTICING AT THE AMBULATORY CARE FACILITY INCLUDING MEDICAL DIRECTOR/DOCTOR IN CHARGE BELOW OR LIST IS ATTACHED LIST OF NURSES PRACTICING AT THE AMBULATORY CARE FACILITY INCLUDING NURSE DIRECTOR/NURSE IN CHARGE BELOW OR LIST IS ATTACHED LIST OF ALLIED HEALTH PRACTITIONERS PRACTICING AT THE AMBULATORY CARE FACILITY BELOW OR LIST IS ATTACHED

4 5. OPERATIONAL INFORMATION Expected Hours of Operation: Sunday : From To Thursday From To Monday: From To Friday; From To Tuesday: From To Saturday: From To Type of facility See definitions in Guidance Wednesday: From To Clinic Indicate what clinic type below: On call hours: From To Centre Indicate what centre type below: General Medical Specialist Medical Medical Dental General Dental Specialist Dental Specialty Multi-Specialty Allied Health School / Company Primary Health Care Centre Diagnostic Clinic, Radiology Optometry Shop Diagnostic Clinic, Laboratory Identify Scope of Services: Or attach list of proposed services. Expected Opening, Moving, or Completion : Preferred pre-license Inspection s : From: To: Temporary Closure Notification (insert dates) if applicable From : To: A 14-day notice is required for scheduling an opening or change of location inspection. Drugs may not be stocked prior to inspection and approval. An inspector will call prior to the requested date to confirm readiness for inspection. If the inspector does not call to confirm the date, the responsible party should call the Facility Licensure Office at the NHRA to verify the inspection date with the inspector. FOR NHRA USE ONLY: Acknowledgement of Inspection Request Processed: Assigned Inspection : Application Number Assigned Inspected License Number Issued

5 6. DECLARATION I/We the undersigned, certify that I/we am/are the person/s referred to in the foregoing application for licensure registration in the Kingdom of Bahrain, and that the statements herein are true to the best of my/our knowledge, information and belief. I/we understand that, should I/we furnish any false information in this application, such act shall constitute cause for denial, suspension or revocation of the facility license in the Kingdom of Bahrain. PLEASE DO NOT SUBMIT YOUR APPLICATION UNTIL YOU CAN ENCLOSE ALL REQUIRED DOCUMENTATION. 7. CHECKLIST Please use the checklist to make sure that you have attached all necessary documents. Preliminary Approval Full License Approval Copy of CPR Full license proposal Copy of passport Copy of lease agreement with the owner of the real estate on license proposal outline which the facility is built. Architectural Drawings (hard and soft copies) Copy of previous license Copy of all approvals obtained from required departments and organizations in the Kingdom of Bahrain e.g. The Ministry of Industry and Commerce in Bahrain Bahrain Telecommunications Authority. Bahraini Local Municipalities., Incl. Electricity and Water Authority Civil Defence Authority incl. Fire certification/approval. Medical device and equipment engineering approvals Radiation level approvals. Receipt evidencing payment of license fees. Certificate of insurance Other:

HOSPITAL-ANCILLARY-CLINIC PROVIDER CREDENTIALING APPLICATION

HOSPITAL-ANCILLARY-CLINIC PROVIDER CREDENTIALING APPLICATION INSTRUCTIONS: In order to be considered complete: 1. All information must be legible. Please print or type all information 2. Application must be completed in its entirety 3. Must be signed and dated 4.

More information

GENERAL INFORMATION. English Spanish Arabic Chinese French German Hmong Hindi Laotian Philippine Vietnamese Other

GENERAL INFORMATION. English Spanish Arabic Chinese French German Hmong Hindi Laotian Philippine Vietnamese Other **INCOMPLETE APPLICATIONS WILL DELAY THE CREDENTIALING PROCESS** 1. Please print or type ALL responses. 2. If you need additional space to complete a section, please attach additional sheets. 3. If you

More information

Mississippi State Department of Health Application for License Renewal of Ambulatory Surgical Facility Licensure Year: July 1, June 30, 2019

Mississippi State Department of Health Application for License Renewal of Ambulatory Surgical Facility Licensure Year: July 1, June 30, 2019 Mississippi State Department of Health Application for License Renewal of Ambulatory Surgical Facility Licensure Year: July 1, 2018 - June 30, 2019 As authorized and required by Chapter 433, Laws of Mississippi,

More information

APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing.

APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing. State of Florida Department of Business and Professional Regulation Board of Veterinary Medicine Application for Registration of a Veterinary Premise Form # DBPR VM 2 1 of 7 APPLICATION CHECKLIST IMPORTANT

More information

INSTRUCTIONS FOR COMPLETION OF ADVANCED PRACTICE APPLICATION

INSTRUCTIONS FOR COMPLETION OF ADVANCED PRACTICE APPLICATION KANSAS STATE BOARD OF NURSING Landon State Office Building 900 SW Jackson, Ste 1051 Topeka, KS 66612-1230 (785) 296-4929 INSTRUCTIONS FOR COMPLETION OF ADVANCED PRACTICE APPLICATION Licensure in Kansas

More information

Application for Home Care Licensure General Instructions

Application for Home Care Licensure General Instructions Application for Home Care Licensure General Instructions General Instructions This application form should be used by individuals and organizations seeking initial approval to operate as a licensed home

More information

Application for Home Care Licensure General Instructions

Application for Home Care Licensure General Instructions Application for Home Care Licensure General Instructions General Instructions This application form should be used by individuals and organizations seeking initial approval to operate as a licensed home

More information

NOTE BY THE TECHNICAL SECRETARIAT

NOTE BY THE TECHNICAL SECRETARIAT OPCW Technical Secretariat International Cooperation and Assistance Division S/816/2010 25 February 2010 ENGLISH only NOTE BY THE TECHNICAL SECRETARIAT CALL FOR NOMINATIONS FOR AN ADVANCED TRAINING COURSE

More information

Islami Bank Bangladesh Limited Human Resources Division Head Office, Dhaka

Islami Bank Bangladesh Limited Human Resources Division Head Office, Dhaka List of the candidates qualified in the written test for the post of Probationary Officer, 23 rd batch of the Bank. Board 1 Board 2 100106, 100121, 101695, 101740, Required papers 100136, 100208, 101743,

More information

Eye Medical Provider Practice Application

Eye Medical Provider Practice Application and subsidiaries Eye Medical Provider Practice Application How to Join the Avesis Network. Complete and sign the application Complete and sign the W-9 Complete and sign the Credential Verification Release

More information

Rhode Island Department of Health Application and Instructions for Food Business:

Rhode Island Department of Health Application and Instructions for Food Business: RI Department of Health www.health.ri.gov Revised 06/09/2015 Rhode Island Department of Health Application and Instructions for Food Business: Market (n-profit) Name of Business Previous Business Name

More information

Small Business Enterprise Program Participation Plan

Small Business Enterprise Program Participation Plan EXHIBIT H Small Business Enterprise Program Participation Plan Version 5.11.2015 www.transportation.ohio.gov ODOT is an Equal Opportunity Employer and Provider of Services TABLE OF CONTENTS I. PURPOSE...

More information

LIBERTY DENTAL PLAN. Provider Credentialing Application. (* Required Fields) *OFFICE PHONE #: ( ) EMERGENCY PHONE #: ( ) *FAX #: ( )

LIBERTY DENTAL PLAN. Provider Credentialing Application. (* Required Fields) *OFFICE PHONE #: ( ) EMERGENCY PHONE #: ( ) *FAX #: ( ) (Complete one application per Provider) (* Required Fields) Credentialing Information: Owner: Associate: *PROVIDER NAME: DDS DMD Other (specify) *DATE OF BIRTH: / / Gender: Male Female Owning Dentist Name:

More information

KANSAS STATE BOARD OF NURSING Landon State Office Building 900 SW Jackson, Ste 1051 Topeka, KS (785)

KANSAS STATE BOARD OF NURSING Landon State Office Building 900 SW Jackson, Ste 1051 Topeka, KS (785) KANSAS STATE BOARD OF NURSING Landon State Office Building 900 SW Jackson, Ste 1051 Topeka, KS 66612-1230 (785) 296-4929 INSTRUCTIONS FOR COMPLETION OF RENEWAL APPLICATION Online Renewal is available!!!

More information

HOSPITAL-ANCILLARY-CLINIC PROVIDER CREDENTIALING APPLICATION

HOSPITAL-ANCILLARY-CLINIC PROVIDER CREDENTIALING APPLICATION HOSPITAL-ANCILLARY-CLINIC PROVIDER CREDENTIALING APPLICATION INSTRUCTIONS: In order to be considered complete: 1. All information must be legible. Please print or type all information 2. Application must

More information

New Mexico Bingo, Raffle, & Pull Tab Renewal Application

New Mexico Bingo, Raffle, & Pull Tab Renewal Application New Mexico Bingo, Raffle, & Pull Tab Renewal Application New Mexico Gaming Control Board 4900 Alameda Blvd. NE Albuquerque, NM 87113 : (505 841-9700 Fax: (505 841-9725 WEB: WWW.NMGCB.ORG Bingo, Raffle,

More information

DMS Education Grant Application PART ONE Personal Information

DMS Education Grant Application PART ONE Personal Information PART ONE Personal Information PAGE 1/14 Full Name (Surname, First, Middle): Date of Birth (dd/mm/yyyy): Gender: Male Female Place of Birth: Nationality: Caymanian Status: Yes No Place of Residence (Full

More information

STATE OF MAINE NURSING HOME ADMINISTRATORS LICENSING BOARD APPLICATION FOR LICENSURE. Temporary Administrator

STATE OF MAINE NURSING HOME ADMINISTRATORS LICENSING BOARD APPLICATION FOR LICENSURE. Temporary Administrator STATE OF MAINE NURSING HOME ADMINISTRATORS LICENSING BOARD APPLICATION FOR LICENSURE Temporary Administrator Department of Professional and Financial Regulation Office of Professional and Occupational

More information

INSTRUCTION TO APPLICANTS A. ADMINISTRATOR IN TRAINING PROGRAM:

INSTRUCTION TO APPLICANTS A. ADMINISTRATOR IN TRAINING PROGRAM: Vermont Secretary of State Office of Professional Regulation 89 Main St., 3 rd Floor Montpelier VT 05620-3402 Nursing Home Administrators INSTRUCTION TO APPLICANTS A. ADMINISTRATOR IN TRAINING PROGRAM:

More information

VNSNY CHOICE PRACTITIONER CREDENTIALING APPLICATION

VNSNY CHOICE PRACTITIONER CREDENTIALING APPLICATION Attached please find an application for participation with VNSNY CHOICE. Upon completion, please forward this application to: VNSNY CHOICE Attn: Provider Relations Network Development 1250 Broadway - 11th

More information

Ensure that the application is legible; please print in ink or type information onto form.

Ensure that the application is legible; please print in ink or type information onto form. GENERAL INSTRUCTIONS Submit 3 copies of each application. Keep a 4 th copy for your records Attach 3 copies of all supporting documentation. For example: Specifications of the proposed project, including

More information

Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE AS A REGISTERED NURSE

Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE AS A REGISTERED NURSE Vermont Secretary of State 89 Main St., 3 rd Floor Montpelier VT 05620-3402 Nursing (802) 828-2396 www.vtprofessionals.org INSTRUCTION TO APPLICANTS FOR LICENSURE AS A REGISTERED NURSE RE-ENTRY Applicant

More information

POST-GRADUATE CERTIFICATE IN THE THEORY OF ACCOUNTING (CTA) APPLICATION FORM 2016

POST-GRADUATE CERTIFICATE IN THE THEORY OF ACCOUNTING (CTA) APPLICATION FORM 2016 POST-GRADUATE CERTIFICATE IN THE THEORY OF ACCOUNTING (CTA) APPLICATION FORM 2016 BEFORE YOU START COMPLETING THEIS FORM PLEASE READ AND SIGN THE FOLLOWING CONSENT TO COLLECT PERSONAL INFORMATION. I accept,

More information

NEW HAVEN UNIFIED SCHOOL DISTRICT REQUEST FOR BID

NEW HAVEN UNIFIED SCHOOL DISTRICT REQUEST FOR BID For DSA PROJECT INSPECTOR (CLASS 1) Itliong Vera Cruz Middle School 21 st Century Classroom Building RFP # 779 DSA PROJECT INSPECTOR (CLASS 1) Itliong Vera Cruz Middle School 21 st Century Classroom Building

More information

Application form for Certification

Application form for Certification Application form for Certification The following information is important. Please read it carefully before filling in your application form. If you need any help in completing it, please contact an IRCA

More information

SPEECH-LANGUAGE PATHOLOGY ASSISTANT (SLPA) REQUIREMENTS AND INSTRUCTIONS

SPEECH-LANGUAGE PATHOLOGY ASSISTANT (SLPA) REQUIREMENTS AND INSTRUCTIONS South Carolina Board of Examiners in Speech-Language Pathology and Audiology 110 Centerview Dr. Columbia SC 29210 P.O. Box 11329 Columbia SC 29211-1329 Phone: 803-896-4655 Contact.Speech@llr.sc.gov Fax:

More information

SC Uniform Managed Care Provider Credentialing Application

SC Uniform Managed Care Provider Credentialing Application SC Uniform Managed Care Provider Credentialing Application I. PERSONAL INFORMATION Solo Practice Group Practice Name: Last First M.I. Suffix Degree Maiden and/or other name List W-9 name if different Place

More information

Instructions and Resource Page for Application for a License to Operate a Child Care Facility

Instructions and Resource Page for Application for a License to Operate a Child Care Facility Instructions and Resource Page for Application for a License to Operate a Child Care Facility Instructions: All information on this application must be truthful and correct. Complete this application in

More information

New Jersey Motor Vehicle Commission

New Jersey Motor Vehicle Commission Instructor License Type & Number New Jersey REMEDIAL DRIVER EDUCATION PROGRAM INITIAL INSTRUCTOR LICENSE APPLICATION Official Use Only P.O. Box 170 Trenton, New Jersey 08666-0170 (609) 292-6500 ext.5094

More information

REVISIONS TO Bulletin 137 Louisiana Early Learning Center Licensing Regulations

REVISIONS TO Bulletin 137 Louisiana Early Learning Center Licensing Regulations DRAFT DRAFT DRAFT REVISIONS TO Bulletin 137 Louisiana Early Learning Center Licensing Regulations 103. Definitions Academic Approval--verification by the department that a Type III early learning center

More information

2019 SCHOLARSHIP APPLICATION FOR M. Late applications will not be accepted. Please address all applications and enquires to:

2019 SCHOLARSHIP APPLICATION FOR M. Late applications will not be accepted. Please address all applications and enquires to: 2019 SCHOLARSHIP APPLICATION FOR M SPORTS SCHOLARSHIP St Paul s Scholarships are awarded to those who are most able to demonstrate their capacity to make an exceptional contribution to the School community

More information

State of Florida Department of Health. Board of Osteopathic Medicine. Application for Registration as an Osteopathic Physician in Training

State of Florida Department of Health. Board of Osteopathic Medicine. Application for Registration as an Osteopathic Physician in Training State of Florida Department of Health Board of Osteopathic Medicine Application for Registration as an Osteopathic Physician in Training Board of Osteopathic Medicine 4052 Bald Cypress Way, #C-06 Tallahassee,

More information

National Accreditation Policy for Health Care Facilities 2016

National Accreditation Policy for Health Care Facilities 2016 National Accreditation Policy for Health Care Facilities 2016 TABLE OF CONTENTS Section 1: INTRODUCTION 1.1 About NHRA... 4 1.2 The purpose of NHRA accreditation... 4 1.3 The benefits of NHRA accreditation...

More information

Massage Therapist License Application W 87 Street Pkwy Phone Lenexa, KS Fax

Massage Therapist License Application W 87 Street Pkwy Phone Lenexa, KS Fax Massage Therapist License Application 17101 W 87 Street Pkwy Phone 913-477-7725 Lenexa, KS 66109 Fax 913-477-7730 www.lenexa.com NOTE: Any failure to fully or truthfully answer any question or provide

More information

Optometry Renewal Application

Optometry Renewal Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Optometry Renewal Application Board of Optometry Renewal Clerk (802) 828-1505

More information

APPLICATION REQUIREMENTS Fees: $105 Make check payable to the Florida Department of Business and Professional Regulation.

APPLICATION REQUIREMENTS Fees: $105 Make check payable to the Florida Department of Business and Professional Regulation. State of Florida Regulatory Council of Community Association Managers Application for Community Association Management Firm License Form # DBPR CAM 2 1 of 5 This application is used to request initial

More information

New Jersey Motor Vehicle Commission

New Jersey Motor Vehicle Commission New Jersey STATE OF NEW JERSEY P.O. Box 170 Trenton, New Jersey 08666-0170 (609) 292-6500 ext. 5014 FAX# 609-292-4400 mvcblsprocessing@mvc.nj.gov Chris Christie Governor Kim Guadagno Lt. Governor Raymond

More information

JOINT VENTURE CONSULTANCY PRACTICES REGISTRATION FORM CICF 5

JOINT VENTURE CONSULTANCY PRACTICES REGISTRATION FORM CICF 5 JOINT VENTURE CONSULTANCY PRACTICES REGISTRATION FORM CICF 5 IMPORTANT NOTICE IT IS VERY IMPORTANT THAT YOU READ THE PROCEDURES, RULES, TERMS AND CONDITIONS FOR REGISTRATION INCLUDED IN THIS DOCUMENT BEFORE

More information

Optometry Renewal/Reinstatement Application

Optometry Renewal/Reinstatement Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Board of Optometry 802-828-1505 renewalclerk@sec.state.vt.us www.vtprofessionals.org

More information

Secondary Suite Grant Funding Program

Secondary Suite Grant Funding Program Secondary Suite Grant Funding Program Information Guide and Application Form Upgrading an Existing Secondary, Garage or Garden Suite Upgrade Existing Secondary, Garage or Garden Suite in Existing Home

More information

Dunia. Young Leaders Scholarship Program. Application Form. Empowering people, Enabling success, Enriching lives

Dunia. Young Leaders Scholarship Program. Application Form. Empowering people, Enabling success, Enriching lives Dunia Young Leaders Scholarship Program Empowering people, Enabling success, Enriching lives Application Form Thank you for your interest in the Dunia Young Leaders Scholarship Program. Dear Parent, Thank

More information

Private Investigator and/or Security Guard Qualifying Agent Application

Private Investigator and/or Security Guard Qualifying Agent Application Vermont Secretary of State Office of Professional Regulation 89 Main Street, 3 rd Floor Montpelier VT 05620-3402 Kara Shangraw Licensing Board Specialist (802) 828-1134 kara.shangraw@sec.state.vt.us www.vtprofessionals.org

More information

State of Florida Department of Health. Board of Osteopathic Medicine. Application for Registration as an Osteopathic Physician in Training

State of Florida Department of Health. Board of Osteopathic Medicine. Application for Registration as an Osteopathic Physician in Training State of Florida Department of Health Board of Osteopathic Medicine Application for Registration as an Osteopathic Physician in Training Board of Osteopathic Medicine 4052 Bald Cypress Way, #C-06 Tallahassee,

More information

INSTRUCTIONS FOR REINSTATEMENT, REACTIVATION AND RESUMPTION OF PRACTICE APPLICATION OF A NEW JERSEY LICENSE

INSTRUCTIONS FOR REINSTATEMENT, REACTIVATION AND RESUMPTION OF PRACTICE APPLICATION OF A NEW JERSEY LICENSE Division of Consum er Affairs State Board of Professional Engineers and Land Surveyors rd 124 Halsey Street, 3 Floor, Newark, NJ 07102 www.njconsumeraffairs.gov (973) 504-6460 INSTRUCTIONS FOR REINSTATEMENT,

More information

Historic Preservation

Historic Preservation A guide to the Individual Designation of Historic Properties Historic Preservation Planning Services Department, 50 West 13th Street, Dubuque, IA 52001-4864 (563) 589-4210 e-mail: planning@cityofdubuque.org

More information

Molina Healthcare of Washington, Inc. Health Delivery Organization (HDO) Application

Molina Healthcare of Washington, Inc. Health Delivery Organization (HDO) Application INSTRUCTIONS: If your organization has multiple physical locations/businesses, include a separate full application for any facility grouping for which there is an independent facility survey and/or facility

More information

Center Name: British Council

Center Name: British Council GCE O-Level OCTOBER / NOVEMBER 2014 CAMBRIDGE INTERNATIONAL EXAMINATION Staple your photo GENERAL CERTIFICATE OF EDUCATION ORDINARY LEVEL here. Write name at Candidate No: (For Office use only) the back

More information

NATIONAL ACCREDITATION POLICY FOR HEALTHCARE FACILITIES

NATIONAL ACCREDITATION POLICY FOR HEALTHCARE FACILITIES NATIONAL ACCREDITATION POLICY FOR HEALTHCARE FACILITIES V2.0 Effective: October 2017 National Accreditation Policy for Healthcare Facilities 1 2 National Accreditation Policy for Healthcare Facilities

More information

APPLICATION FOR HEALTH PROFESSIONAL LICENSURE

APPLICATION FOR HEALTH PROFESSIONAL LICENSURE 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

More information

World Trade Center Health Program FDNY Responder Eligibility Application

World Trade Center Health Program FDNY Responder Eligibility Application World Trade Center Health Program FDNY Responder Eligibility Application Form Approved OMB No. 0920-0891 Exp. Date 12/31/2014 A World Trade Center (WTC) Health Program FDNY Responder is a member of the

More information

SOUTHERN NEVADA HEALTH DISTRICT APPLICATION FOR RENEWAL OF AMBULANCE PERMIT

SOUTHERN NEVADA HEALTH DISTRICT APPLICATION FOR RENEWAL OF AMBULANCE PERMIT SOUTHERN NEVADA HEALTH DISTRICT APPLICATION FOR RENEWAL OF AMBULANCE PERMIT (INSTRUCTIONS: This application must be filled out in total and either delivered to the EMS office at the Southern Nevada Health

More information

10111 Richmond Avenue, Suite 400, Houston, Texas (713) / (866) (Toll Free) / (713) (Fax)

10111 Richmond Avenue, Suite 400, Houston, Texas (713) / (866) (Toll Free) / (713) (Fax) Application Date: \ \ Date Available: \ \ Provider s Name: O MD O DO O PA O NP SS # : City: State: Zip: Home Phone ( ) Work Phone ( ) Pager ( ) Cell Phone ( ) E-Mail address: Driver s Lic. # Expires: \

More information

NIGERIAN ELECTRICITY REGULATORY COMMISSION SCHEDULE 2 APPLICATION FORM FOR A LICENCE. (Pursuant to S.70 Electric Power Sector Reform Act, 2005)

NIGERIAN ELECTRICITY REGULATORY COMMISSION SCHEDULE 2 APPLICATION FORM FOR A LICENCE. (Pursuant to S.70 Electric Power Sector Reform Act, 2005) NIGERIAN ELECTRICITY REGULATORY COMMISSION SCHEDULE 2 APPLICATION FORM FOR A LICENCE (Pursuant to S.70 Electric Power Sector Reform Act, 2005) IMPORTANT NOTE: Your Application is incomplete unless all

More information

National Health Regulatory Authority Kingdom of Bahrain

National Health Regulatory Authority Kingdom of Bahrain National Health Regulatory Authority Kingdom of Bahrain THE NHRA GUIDANCE ON SERIOUS ADVERSE EVENT MANAGEMENT AND REPORTING THE PURPOSE OF THIS DOCUMENT IS TO OUTLINE SERIOUS ADVERSE EVENTS THAT SHOULD

More information

IMPORTANT! If your company does not meet these three conditions, please return to our website to select a different application type.

IMPORTANT! If your company does not meet these three conditions, please return to our website to select a different application type. IMPORTANT! Please read carefully before beginning your Re-Verification application. 1. Please make sure you have selected the correct application type. The Re-Verification Application is for all suppliers

More information

Application Form. Two copies of government issued identification. Two recent passport photos of yourself that are no more than six months old.

Application Form. Two copies of government issued identification. Two recent passport photos of yourself that are no more than six months old. Application Form IMPORTANT: You must submit along with this form Verification of Experience Form. Verification of Experience Form and this Application form must be signed and submitted together with all

More information

Defines adult foster care and license categories Defines licensee

Defines adult foster care and license categories Defines licensee 1 PURPOSE LEGAL BASE Act 218 Adult Foster Care This Manual establishes the policy and procedures to be followed by regulatory staff when the licensee requests a change in the terms or modification of a

More information

FORM C RELOCATION OF AN EXISTING CERTIFICATE OF APPROVAL OR RELOCATION WITH A PHYSICAL EXPANSION/ EXPANSION OF SERVICES/SIGNIFICANT CHANGE IN CAPACITY

FORM C RELOCATION OF AN EXISTING CERTIFICATE OF APPROVAL OR RELOCATION WITH A PHYSICAL EXPANSION/ EXPANSION OF SERVICES/SIGNIFICANT CHANGE IN CAPACITY DIAGNOSTIC FACILITIES ADMINISTRATION PRIVATELY OWNED FACILITY APPLICATION FORM C RELOCATION OF AN EXISTING CERTIFICATE OF APPROVAL OR RELOCATION WITH A PHYSICAL EXPANSION/ EXPANSION OF SERVICES/SIGNIFICANT

More information

Application for Temporary Authorization Original OR Renewal (Instructional)

Application for Temporary Authorization Original OR Renewal (Instructional) FORM 38 (Revised 1/02) PART I - Received by County PART II - PERSONAL STATEMENT OF APPLICANT PLEASE TYPE OR PRINT IN INK. Application for Original OR Renewal (Instructional) WV DEPARTMENT OF EDUCATION

More information

STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH Subsurface Sewage Disposal System INSTALLER License Application

STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH Subsurface Sewage Disposal System INSTALLER License Application STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH Subsurface Sewage Disposal System INSTALLER License Application General Policies and Procedures IMPORTANT: THE DEPARTMENT WILL NOT REVIEW HAND-DELIVERED

More information

CREDENTIALING PROCEDURES MANUAL MEMORIAL HOSPITAL OF SOUTH BEND, INC. SOUTH BEND, INDIANA

CREDENTIALING PROCEDURES MANUAL MEMORIAL HOSPITAL OF SOUTH BEND, INC. SOUTH BEND, INDIANA MEMORIAL HOSPITAL OF SOUTH BEND, INC. SOUTH BEND, INDIANA January 16, 1984 Revised: October 18, 1984 January 19, 1989 April 17, 1989 April 26, 1990 December 20, 1990 January 21, 1993 May 27, 1993 July

More information

247 CMR: BOARD OF REGISTRATION IN PHARMACY 247 CMR 21.00: REGISTRATION OF OUTSOURCING FACILITIES. Section

247 CMR: BOARD OF REGISTRATION IN PHARMACY 247 CMR 21.00: REGISTRATION OF OUTSOURCING FACILITIES. Section 247 CMR 21.00: REGISTRATION OF OUTSOURCING FACILITIES Section 21.01: Purpose 21.02: Outsourcing Facility Registration Requirements 21.03: Provisional Outsourcing Facility Registration Requirements 21.04:

More information

AGA KHAN UNIVERSITY SCHOOL OF NURSING AND MIDWIFERY, TANZANIA APPLICATION FOR ADMISSION

AGA KHAN UNIVERSITY SCHOOL OF NURSING AND MIDWIFERY, TANZANIA APPLICATION FOR ADMISSION Application No. / / / / / / AGA KHAN UNIVERSITY SCHOOL OF NURSING AND MIDWIFERY, TANZANIA APPLICATION FOR ADMISSION POST-RN BACHELOR OF SCIENCE IN NURSING DEGREE PROGRAMME (BSCN) The AKU Post-RN BScN degree

More information

APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing.

APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing. 1 of 11 State of Florida Department of Business and Professional Regulation Building Code Administrators and Inspectors Board Application for Authorization to Take the Principles and Practice Examination

More information

SAN FRANCISCO POLICE DEPARTMENT COMMERCIAL PARKING LOTS AND PARKING GARAGES APPLICATION (PLEASE PRINT CLEARLY IN INK, OR TYPE YOUR RESPONSE)

SAN FRANCISCO POLICE DEPARTMENT COMMERCIAL PARKING LOTS AND PARKING GARAGES APPLICATION (PLEASE PRINT CLEARLY IN INK, OR TYPE YOUR RESPONSE) SAN FRANCISCO POLICE DEPARTMENT COMMERCIAL PARKING LOTS AND PARKING GARAGES APPLICATION (PLEASE PRINT CLEARLY IN INK, OR TYPE YOUR RESPONSE) DATE: Receipt #: (SFPD Use only) TYPE OF APPLICATION: (Please

More information

APPLICATION CHECKLIST IMPORTANT

APPLICATION CHECKLIST IMPORTANT State of Florida Department of Business and Professional Regulation Division of Professions: Talent Agencies Application for Change of Owner or Operator Form # DBPR TA-2 APPLICATION CHECKLIST IMPORTANT

More information

SPEECH-LANGUAGE PATHOLOGY ASSISTANT (SLPA) REQUIREMENTS AND INSTRUCTIONS

SPEECH-LANGUAGE PATHOLOGY ASSISTANT (SLPA) REQUIREMENTS AND INSTRUCTIONS South Carolina Department of Labor, Licensing and Regulation South Carolina Board of Examiners in Speech-Language Pathology and Audiology 110 Centerview Dr. Columbia SC 29210 P.O. Box 11329 Columbia SC

More information

APPLICATION FOR INCLUSION IN THE DENTAL LIST OF THE HEALTH AND SOCIAL CARE BOARD

APPLICATION FOR INCLUSION IN THE DENTAL LIST OF THE HEALTH AND SOCIAL CARE BOARD HS48 [Updated Apr 15] APPLICATION FOR INCLUSION IN THE DENTAL LIST OF THE HEALTH AND SOCIAL CARE BOARD PLEASE COMPLETE ALL RELEVANT SECTIONS OF THIS FORM. Return the completed form to the Health and Social

More information

NATIONAL COUNCIL FOR CONSTRUCTION

NATIONAL COUNCIL FOR CONSTRUCTION NATIONAL COUNCIL FOR CONSTRUCTION REGISTRATION OF CONTRACTORS HEAD OFFICE REGIONAL OFFICE Off Sheki Sheki Road, Plot 1609/1625, Light Industrial Area Mukuba Pension House, Room 209, 212, & 213 P.O. Box

More information

Professional Credential Services, Inc.

Professional Credential Services, Inc. Professional Credential Services, Inc. P.O. Box 198689 - Nashville, TN 37219-8689 www.pcshq.com Licensure Application for Occupational Therapists For the Massachusetts Board of Allied Health Professionals

More information

AGA KHAN UNIVERSITY SCHOOL OF NURSING AND MIDWIFERY, UGANDA APPLICATION FOR ADMISSION

AGA KHAN UNIVERSITY SCHOOL OF NURSING AND MIDWIFERY, UGANDA APPLICATION FOR ADMISSION Application No. / / / / / / AGA KHAN UNIVERSITY SCHOOL OF NURSING AND MIDWIFERY, UGANDA APPLICATION FOR ADMISSION DIPLOMA IN GENERAL NURSING The AKU Diploma in General Nursing is a two-year programme (four

More information

NEW MEXICO EMS PROVIDER 2017 LICENSURE RENEWAL APPLICATION

NEW MEXICO EMS PROVIDER 2017 LICENSURE RENEWAL APPLICATION PLEASE PRINT OR TYPE APPLICATIONS MUST HAVE ORIGINAL SIGNATURES NM EMS License # * SSN of Birth Last Name First Name Middle Initial Gender: Male Female Has your name changed since your last renewal? Yes

More information

LONDON COMMUNITY GRANTS. Innovation & Capital Stream Questions

LONDON COMMUNITY GRANTS. Innovation & Capital Stream Questions LONDON COMMUNITY GRANTS 2017 Innovation & Capital Stream Questions 2 LONDON COMMUNITY GRANTS: INNOVATION STREAM APPLICATION QUESTIONS For questions about the London Community Grants Program, please contact

More information

Professional Credential Services, Inc.

Professional Credential Services, Inc. Professional Credential Services, Inc. P.O. Box 198689 - Nashville, TN 37219-8689 www.pcshq.com Licensure Application for Athletic Trainers For the Massachusetts Board of Allied Health Professionals If

More information

To Apply for BlueCross BlueShield of South Carolina and BlueChoice HealthPlan

To Apply for BlueCross BlueShield of South Carolina and BlueChoice HealthPlan To Apply for BlueCross BlueShield of South Carolina and BlueChoice HealthPlan 1. Complete the SC Uniform Managed Care Provider Credentialing Application. 2. Enclose copies of the following items: A. State

More information

Application Form. Welsh Government Learning Grant for Further Education 2014/15. student finance wales

Application Form. Welsh Government Learning Grant for Further Education 2014/15.  student finance wales student finance wales Welsh Government Learning Grant for Further Education 2014/15 Application Form sound advice on STUDENT FINANCE www.studentfinancewales.co.uk/wglgfe How to complete this application

More information

Contaminated Sites Grant Program

Contaminated Sites Grant Program The Contaminated Sites Grant Program provides a grant of up to 100% of restoration costs for new developments on restored properties in the core areas (up to a maximum of $1,500.00 per new residential

More information

NATIONAL RESEARCH DEVELOPMENT CORPORATION TECHNO-COMMERCIAL SUPPORT FOR PROMISING INVENTIONS / INNOVATIONS GUIDELINES

NATIONAL RESEARCH DEVELOPMENT CORPORATION TECHNO-COMMERCIAL SUPPORT FOR PROMISING INVENTIONS / INNOVATIONS GUIDELINES NATIONAL RESEARCH DEVELOPMENT CORPORATION TECHNO-COMMERCIAL SUPPORT FOR PROMISING INVENTIONS / INNOVATIONS 1. Background GUIDELINES National Research Development Corporation (NRDC) is a unique organization

More information

CREDENTIALING Section 4

CREDENTIALING Section 4 Overview Credentialing is the process by which the appropriate peer-review bodies of Ohana Health Plan (the Plan) evaluate the credentials and qualifications of providers, i.e., physicians, allied health

More information

PRACTICE INFORMATION AND LETTER AGREEMENT FORM. COMPLETE, SIGN AND RETURN TO: One Huntington Quadrangle Suite 1N09 Melville, NY 11747

PRACTICE INFORMATION AND LETTER AGREEMENT FORM. COMPLETE, SIGN AND RETURN TO: One Huntington Quadrangle Suite 1N09 Melville, NY 11747 PRACTICE INFORMATION AND LETTER AGREEMENT FORM COMPLETE, SIGN AND RETURN TO: One Huntington Quadrangle Suite 1N09 Melville, NY 11747 PERSONAL DATA Last Name First Name License Number Tax I.D. Number for

More information

**All fees are inclusive of GST PEARSON EDEXCEL INTERNATIONAL GCSE EXAMINATIONS (IGCSE)

**All fees are inclusive of GST PEARSON EDEXCEL INTERNATIONAL GCSE EXAMINATIONS (IGCSE) **All fees are inclusive of GST PEARSON EDEXCEL INTERNATIONAL GCSE EXAMINATIONS (IGCSE) Centre Name MAY/JUNE 2016 PHOTO Affix your most recent passport size photo here (write your name at the back of the

More information

Professional Credential Services, Inc.

Professional Credential Services, Inc. Professional Credential Services, Inc. P.O. Box 198689 - Nashville, TN 37219-8689 www.pcshq.com Examination & Licensure Application for Physical Therapists For the Massachusetts Board of Allied Health

More information

NURSING HOME ADMINISTRATOR REQUIREMENTS AND INSTRUCTIONS

NURSING HOME ADMINISTRATOR REQUIREMENTS AND INSTRUCTIONS South Carolina Department of Labor, Licensing and Regulation South Carolina Board of Long Term Health Care Administrators 110 Centerview Dr. Columbia SC 29210 P.O. Box 11329 Columbia SC 29211-1329 Phone:

More information

Chapel Bursary application for entry in 2017

Chapel Bursary application for entry in 2017 Chapel Bursary application for entry in 2017 BURSARY The Chapel bursary is available for new students in years 9 to 13 who are actively involved in the Anglican Church. This bursary offers up to 50% off

More information

A. LICENSE BY EDUCATION

A. LICENSE BY EDUCATION Vermont Secretary of State Office of Professional Regulation 89 Main Street, 3 rd Floor Montpelier VT 05620-3402 Aprille Morrison (802) 828-2373 www.vtprofessionals.org Aprille.Morrison@sec.state.vt.us

More information

Texas Department of Criminal Justice-Community Justice Assistance Division Battering Intervention and Prevention Program (BIPP) Accreditation Process

Texas Department of Criminal Justice-Community Justice Assistance Division Battering Intervention and Prevention Program (BIPP) Accreditation Process Texas Department of Criminal Justice-Community Justice Assistance Division Battering Intervention and Prevention Program (BIPP) Accreditation Process SUBJECT: Battering Intervention and Prevention Program

More information

Registered Nurse Renewal Application

Registered Nurse Renewal Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Current Expiration 03/31/2013 You Must Complete The Information Below:

More information

(NOTE : Filling of both forms is mandatory The information furnished by the applicants shall be treated in strict confidence.)

(NOTE : Filling of both forms is mandatory The information furnished by the applicants shall be treated in strict confidence.) BRING BUSINESS, EDUCATION, DEVELOPMENT AND GOVERNMENT TO RURAL INDIA Under the aegis of the National e-governance plan of Rural Banking Development Authority of India Application No 18 M/S RBD Foundation

More information

FEED-IN TARIFF POLICY APPLICATION AND IMPLEMENTATION GUIDELINES

FEED-IN TARIFF POLICY APPLICATION AND IMPLEMENTATION GUIDELINES Ministry of Energy FEED-IN TARIFF POLICY APPLICATION AND IMPLEMENTATION GUIDELINES 1 December, 2012 TABLE OF CONTENTS 1 INTRODUCTION 3 2 OVERVIEW OF THE FiT PROCEDURE 3 3 EXPRESSION OF INTEREST APPLICATION

More information

NORTH CAROLINA STATE BOARD OF DENTAL EXAMINERS

NORTH CAROLINA STATE BOARD OF DENTAL EXAMINERS NORTH CAROLINA STATE BOARD OF DENTAL EXAMINERS LIMITED VOLUNTEER DENTAL LICENSE INFORMATION PACKET This information packet includes the following: 1) A copy of the Limited Volunteer Dental License Rules

More information

Professional Credential Services, Inc.

Professional Credential Services, Inc. Professional Credential Services, Inc. P.O. Box 198689 - Nashville, TN 37219-8689 www.pcshq.com Examination & Licensure Application for Physical Therapist Assistants For the Massachusetts Board of Allied

More information

Part 2620 Radiologist Assistants. Part 2620 Chapter 1: The Practice of Radiologist Assistants

Part 2620 Radiologist Assistants. Part 2620 Chapter 1: The Practice of Radiologist Assistants Part 2620 Radiologist Assistants Part 2620 Chapter 1: The Practice of Radiologist Assistants Rule 1.1 Scope. The following rules pertain to radiologist assistants performing any x-ray procedure or operating

More information

Vermont Board of Nursing INSTRUCTION TO APPLICANTS

Vermont Board of Nursing INSTRUCTION TO APPLICANTS Vermont Secretary of State 89 Main St., 3 rd Floor Montpelier VT 05620-3402 Nursing Foreign_nurse@sec.state.vt.us www.vtprofessionals.org INSTRUCTION TO APPLICANTS NCLEX RETAKE (International) Applicant

More information

AGA KHAN UNIVERSITY SCHOOL OF NURSING AND MIDWIFERY, UGANDA APPLICATION FOR ADMISSION

AGA KHAN UNIVERSITY SCHOOL OF NURSING AND MIDWIFERY, UGANDA APPLICATION FOR ADMISSION Application No. / / / / / / AGA KHAN UNIVERSITY SCHOOL OF NURSING AND MIDWIFERY, UGANDA APPLICATION FOR ADMISSION POST-RM BACHELOR OF SCIENCE IN MIDWIFERY DEGREE PROGRAMME (BSCM) The AKU Post-RM BScM degree

More information

WI Procedures for Applying for Examination (Work Experience Instructor Candidate)

WI Procedures for Applying for Examination (Work Experience Instructor Candidate) W WI Procedures for Applying for Examination (Work Experience Instructor Candidate) The following information will assist you with the necessary procedures for applying for your examination: DEPARTMENT

More information

First-time Buyer: Home Renovation Grant

First-time Buyer: Home Renovation Grant First-time Buyer: Home Renovation Grant Application Form Please send completed forms along with any other documents to the following address: Empty Homes Team Gwynedd Council Cae Penarlag Dolgellau Gwynedd

More information

Stewartville, MN Business Incubation Program Guidelines

Stewartville, MN Business Incubation Program Guidelines Stewartville, MN Business Incubation Program Guidelines Goal: To encourage the creation and support of new for-profit businesses that maintain and enhance a sustainable and diverse business climate within

More information

April 23, Dear Village of Lisle Business Owner:

April 23, Dear Village of Lisle Business Owner: April 23, 2018 Dear Village of Lisle Business Owner: It is time to renew your Village of Lisle Business Registration. The renewal fee is discounted to $25 if submitted on or before Friday, June 15, 2018.

More information

INTRODUCTION CHANGES FROM THE PREVIOUS YEAR S GRANT

INTRODUCTION CHANGES FROM THE PREVIOUS YEAR S GRANT Updated: 1 March 2014 1 Fasset Grant Guidelines 2014/2015 For the Period 1 January to 31 December 2014 Postal Address: PO Box 6801, Cresta, 2118 Phone: (011) 476-8570 Fax (Grant Applications): 086 574

More information

Professional Credential Services, Inc.

Professional Credential Services, Inc. Professional Credential Services, Inc. P.O. Box 198689 - Nashville, TN 37219-8689 www.pcshq.com Examination & Licensure Application for Physical Therapist For the Massachusetts Board of Allied Health Professionals

More information