Personal Information |
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First Name: |
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Middle: |
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Last Name: |
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Date of Birth |
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Nationality: |
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Place of Birth: |
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Age: |
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Sex: |
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Marital Status: |
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Telephone (home): |
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Telephone (work): |
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Postal Address (work): |
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Postal Address (home): |
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Name, Postal Address
& Telephone number of a local contact person: |
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Medical Degree, College/University Name, Date Degree Obtained: |
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List of Additional and/or Higher Qualifications with dates: |
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State type of practice you which to pursue |
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Professional References: Name 3 and state full postal address: |
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Have any proceedings ever been initiated against you in a court of law by a medical licensing authority? (if yes provide details) |
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Required Documents |
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| Applicants are advised to submit the following items once registration form is submitted. Be sure to include your name and contact information when submitting required documents: Click here to submit required documents |
* You are requested to upload an unmounted photograph of yourself (Any photo of recent date which provides a good likeness is sufficient):
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*Notarized Copies of the Medical Qualifications Documents (or original documents to be inspected by the Chairman or the Registrar):
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(Please note any Graduate of Universities considered to be “Off Shore” Medical Schools are advised that copies of pass certificate in USLME 1& 2, The CAM-C exam, The MCCEE or the PLAB is required for registration.) |
* Detailed Curriculum Vitae (including Full Biographical Data, Medical Education and Post-Graduate Training, Post-Graduate Qualifications, Clinical Experience, Employment History and Research work):
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* Current Certificate of Good Standing issued by the relevant Medical Licensing Authority (original only) attesting as to whether or not the applicant has ever been subject to disciplinary enquiry:
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* Letter from the employing institution confirming consideration or the offer of employment and describing the post offered, which must be received by the Council before the applicant assumes his duties:
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N.B. The applicants who have recently completed Internship must submit certificate of successful completion of prescribed internship.
Note also that Government Employed Physicians are not required to pay a registration fee.
FAILURE TO PROVIDE ALL THE ABOVE DOCUMENTS WILL RESULT IN REJECTION OF THE APPLICATION |
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