Registration Form

Registration Form

April 22, 2025 2025-04-22 13:17

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NAME OF THE APPLICANT

First

Last

FATHER’S NAME

First

Last

PRESENT CORRESPONDENCE ADDRESS

Address Line 1

City

State / Province / Region

Postal Code

Country

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PHONE

DATE OF BIRTH

EMAIL

NATIONALITY

POST GRADUATION MEDICAL DEGREE

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University Name

Passing Month & Year

PRIMARY MEDICAL DEGREE

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University Name

Passing Month & Year

IS THE REGISTRATION/ LICENSE IS RENEWABLE OR PERMANENT

DOCUMENT REQUIRED

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CURRENT REGISTRATION CERTIFICATE IN YOUR OWN COUNTRY (IN ENGLISH)

Click or drag a file to this area to upload.

.jpg | .pdf Formats Only/

PRIMARY MEDICAL DEGREE CERTIFICATE (IN ENGLISH)

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pdf Format Only/

APPLICANT PHOTGRAPH

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.jpg Format Passport size photograph with solid wite or blue Background/

CV

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pdf Format Only/

COPY OF PASSPORT

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pdf Format Only/

POST GRADUATE MEDICAL DEGREE CERTIFICATE (IN ENGLISH)

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pdf Format Only/

RECENT GOOD STANDING CERTIFICATE (IN ENGLISH)

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pdf Format Only/

ARE YOU REGISTERED IN ANY OTHER FOREIGN COUNTRY? IF SO, GIVE NAME OF THE BODY WITH WHICH REGISTERED AND THE NUMER AND DATE OF REGISTRATION.

ARE YOU REGISTERED AS A MEDICAL PRACTITIONER IN YOUR OWN COUNTRY? IF SO PROVIDE THE NAME OF THE BODY WITH WHICH REGISTERED WITH THE REGISTRATION/LICENSE NUMBER AND DATE.