Doctor Registration form

PERSONAL INFORMATION













YES NO

ACADEMIC AND PROFESSIONAL DETAILS OR QUALIFICATIONS

Primary Medical Qualification

TITLE LOCATION START DATE END DATE

Specialist Medical Qualification

TITLE LOCATION START DATE END DATE

Other Professional Qualifications (BCLF, ACLS etc)

TITLE LOCATION START DATE END DATE

Professional Registrations

AUTHORITY REG NO or TYPE START DATE END DATE

LANGUAGES

LANGUAGE ASSESSMENT READING WRITING SPOKEN

PROFESSIONAL WORK HISTORY (Most Recent First)

POSITION/TITLE LOCATION START DATE END DATE ROLE DESCRIPTION AND RESPONSIBILITIES SKILLS FREQUENTLY USED

ADDITIONAL COURSES COMPLETED

TITLE LOCATION DATE

PUBLICATIONS, PRESENTATIONS AND AWARDS

TITLE LOCATION/PUBLICATION DATE

INTERESTS, HOBBIES AND ADDITIONAL INFORMATION

REFERENCE

We require a minimum of two (2) professional references in ENGLISH, once of which must be your current or last employer. Please include their contact information below.

NAME POSITION TELEPHONE EMAIL

DISCLOSURE

Have you ever been convicted of an offence by a court of law or received caution?
YES NO
Have you ever had a complaint against you upheld in your duty as a doctor in any country?
YES NO
Have you ever been suspended from your duty as a doctor in any country?
YES NO
Have you ever been fined, given a warning or reprimanded by a medical regulatory authority in any country?
YES NO
Are you currently under investigation for a complaint by a patient, employing authority, medical regulatory authority or the police in any country?
YES NO

I certify that the statements made by me in answer to the foregoing questions are true, complete and correct to the best of my knowledge and belief. I understand that any misrepresentation or material omission made on any document requested by Sagesa Healthcare or Employers renders you liable to termination or dismissal.