Application for License to Practice as a Health Professional

8/6/2019 Application for License to Practice as a Health Professional

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KINGDOM OF BAHRAIN

MINISTRY OF HEALTH

OFFICE OF LICENSURE & REGISTRATION

Application number

(for ofcial use only)

APPLICATION FOR LICENSE TO PRACTICE AS A HEALTH PROFESSIONAL(please tick one)

1. Personal details

Speciality (please speciy i applicable)

Full name (as it appears in passport)

Previous name (i dierent rom above)

Address

Tel no. (residence)

Tel no. (business)

E-mail

Mobile no.

Fax no.

C PR no. (i you have one)

Passport no.

Country o issue

Date o birth

Male

Female

Gender

Day Month Year

Single

Married

Other:

Marital status

Bahraini

Other:

Nationality

English

Arabic

Other:

Language profciency

Prospective employer/sponsor

Address

Contact name

Tel no. (business)

Mobile no.

Fax no.

E-mail

Please attach

two photos

1 x 1

Doctor

Resident

Senior resident

Specialist

Consultant

Dentist

Resident

Senior resident

Specialist

Consultant

Nurse

General nurse

Practical nurse

Specialist nurse

Midwie

Allied

Dental hygienist

Dietician

ECG technician

Laboratory technician

Allied (cont.)

Nuclear medicine technician

Optometrist

Physiotherapist

Prostetist

Public health inspector

Radiographer

Respiratory technicianSpeech/audio therapist

Other:

Ofce of Licensure & Registration Ministry of Health P. O. Box 12, Manama Kingdom of Bahrain Tel +973 17 279 899 Fax +973 17 232 614


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2. Educational backgroundPlease answer sections 2.12.3 regarding your level o education.

2.1. General educationPlease speciy i you have completed secondary school, i.e., 12 years general education.

Yes

No, highest level attained:

2.2. Professional educationPlease list in chronological order (starting with most recent) your proessional education. Attach additional sheets i necessary.

Name and address o University/Institution

2.3. Continuing educationPlease list in chronological order (starting with most recent) programs o continuing education (e.g., workshops, in-house training, etc.)

that you have attended within the last 5 years only.

ProgramYearstarted

Yearcompleted

Qualifcation ordegree obtained

Name and address o University/Institution Program/courseNo. odays

Date oattendence

Qualifcation orcertifcate obtained

Year o graduation


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3. Work experienceFor health proessionals who have obtained their degrees outside Bahrain, please list in chronological order (starting with most recent) work

experience you have obtained ollowing completion o proessional education.

Employer name and address

TypeGovernment (G),Private (P), Other (O)

Area o experience/specialty Position held

From To

M/Y M/Y

4. Licensure in other countriesFor health proessionals who have obtained their degrees outside Bahrain, please list all licenses which you hold in other countries.

Country Type o licenseLicense authorityIssuedate

Expirationdate

License number


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5. Declaration

I, the undersigned, certiy that I am the person reerred to in the oregoing application or registration as a _____________________________

in the Kingdom o Bahrain, and that the statements herein are true to the best o my knowledge and belie.

I urther afrm that I am o good physical and mental health and o good moral character and I will keep the Bahrain licensure authority

inormed o any criminal charges and/or physical or mental conditions which jeopardize the quality o care rendered by me to the public.

I hereby authorize the Bahrain licensure authority to request any inormation, fles or records to be released rom relevant licensing

authorities, educational acilities, and previous and past employers in connection with the processing o this application.

I have careully read the questions in the oregoing application and have answered them completely, without reservations o any kind

and I declare under penalty o perjury that my answers and all statements made herein are true and correct. Should I urnish any alse

inormation in this application, I understand that such act shall constitute cause or denial, suspension or revocation o my license to

practice in the Kingdom o Bahrain.

Signature Date

6. Documents requiredPlease use the ollowing checklists to make sure that you have submitted all necessary documents.

6.1. Attached documents

Copies o the ollowing items are attached:

C PR card*

Front pages o passport

Birth certifcate

Statutory evidence o any name changeHealth ftness certifcate*

Employer letter

General education certifcate (secondary school)

Proessional education certifcate

Transcript o proessional education

Registration/license in other country (i you have one)CV (i you obtained your degree outside Bahrain)

Other:

Please also attach 2 passport photographs (1 x 1).

* May be submitted upon arrival to Bahrain

6.2. Requested documentation

For health proessionals who have obtained their degrees outside Bahrain only, orms have been sent to the ollowing:

Licensing authority

School/college

Two reerences