Healthcare Professionals Application Form (1)

8/3/2019 Healthcare Professionals Application Form (1)

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APPLICATION FOR HEALTH PROFESSIONAL LICENSURE

Please complete this application on the computer then print and sign.Hand-written applications will not be accepted.

Section 1: Application Details

Have you ever applied tothe Dubai Health Authority(DHA) for licensure?

No Yes

Please give details I am applying for:(please tick the appropriate

category)

Physician or Dentist

Nurse & Midwife

Allied Health

Complementary Alternative Medicine (CAM)I am applying for theprofessional license of:

For Official Use OnlyApproved Title :

_______________________________Employing Facility Section 2: Personal Details (Please enter all details as per passport)

First name (given) Middle name Last name (family/surname) Maiden name (if applicable) DOB: (dd/mm/yyyy) Place of Birth Passport Number Nationality Date of Issue Date of Expiry UAE National ID No Yes Number(if applicable) Address in Home Country: Address in UAE:(if different from above)

Email Address: Tel. (business) Tel. (residence) Tel. (local UAE

contact no)

www.dha.gov.ae [email protected] Page 1 of 7

Passport Size

Photograph
http://www.dha.gov.ae/mailto:[email protected]://www.dha.gov.ae/mailto:[email protected]


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Section 3: Education Information- 1

Name as per Certificate

(If certificate name is different than name as per passport, then pleasesubmit the relevant name change document)

University/Institution Name College Name University Address. City AreaUniversity Country Telephone No.Qualification Attained(e.g. Doctor of Medicine) Major Subject Minor SubjectStudent Identity / Roll No. Attendance Period

From(dd/mm/yyyy)

12/02/2011To(dd/mm/yyyy)

Qualification Conferred Date (dd/mm/yyyy) Education Information 2(When applicable)

Name as per Certificate

(If certificate name is different than name as per passport, then pleasesubmit the relevant name chan e document

University/Institution Name College Name University Address. City Area University Country Telephone No. Qualification Attained(e.g. Doctor of Medicine)

Major Subject Minor Subject Student Identity / Roll No.

Attendance PeriodFromdd/mm/

To dd/mm/

Qualification Conferred Date (dd/mm/yyyy)

Note: If you have more certificates, add them in a separate page.



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Section 4: License Information

Name as per License Issuing Authority Name City Area

Issuing Authority Country Telephone No. License Attained License Type License No. Issue Period

From(dd/mm/yyyy)

To(dd/mm/yyyy) License Conferred Date(dd/mm/yyyy)

Section 5: Experience Details

Please provide FULL details of employer for last 5 years starting in order from latest to the previous employer

First Employer Details Name of the Employer Address Website address (URL) Telephone No EmploymentCode Period of Employment

From(dd/mm/yyyy) To(dd/mm/yyyy)

Job Title / Designation Department Full time / Part time (If part time please specify the agency name if any)

Second Employer Details Name of the Employer Address Website address (URL) Telephone No EmploymentCode Period of Employment





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Third Em lo er Details

Name of the Employer Address Website address (URL) Telephone No EmploymentCode Period of Employment

From(dd/mm/yyyy)

To(dd/mm/yyyy) Job Title / Designation Department Full time / Part time (If part time please specify the agency name if any)Fourth Employer Details Name of the Employer Address Website address (URL) Telephone No EmploymentCode Period of Employment



Fifth Employer Details Name of the Employer Address Website address (URL)

Telephone No EmploymentCode Period of Employment




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Section 6: Declaration

I here by attest that the following questions have been answered to the best of my knowledge:

1. Health status: Do you have any physical, mental or emotional condition whichmay impair your ability to render professional services which are the subject ofthis application?

Yes No

2. License: Has your professional license in any country ever been suspended,revoked or placed on a conditional status? Yes No

3. License: Are there any formal investigation pending against you at this time? Yes No

4. Hospital Sanctions: Have you ever voluntarily surrendered or diminished yourclinical privileges pending an investigation that may have lead to censure,restriction, suspension or revocation of such privileges?

Yes No

5. Criminal Offences: Have you ever been convicted of a felony or involved incharges relating to moral or ethical turpitude? Yes No

6. Disciplinary Actions: Have you ever been the subject of disciplinaryproceedings by any professional association or organisation Yes No

7. Malpractice Insurance Coverage: Has there ever been any malpractice claimsor lawsuits made against you alleging negligence or a treatment failure whichhas been pending, open or closed during any of your health professionalpractices?

Yes No

If you answered yes to any of the above questions; please explain:

I hereby affirm by my signature, that the information I have completed under penalty of perjury is true and correct.Should I furnish any false information in this application I hereby agree that such an act shall constitute cause forthe denial, or suspension or revocation of my license to practice?

Signature: ____________________________________

Date:20/03/2011

Letter of Authorization

I hereby authorize the Dubai Health Authority or DataFlow FZ LLC, its authorized affiliates, agents and

subsidiaries, acting on its behalf to verify information, documentation and back ground verification presented on

my application form including but not limiting to education, employment and licenses.

I hereby grant the authority for the bearer of this letter, with immediate effect, to release all necessary

information to the Dubai Health Authority or DataFlow FZ LLC, its authorized affiliates, agents and subsidiaries.

This information / documentation may contain but is not limited to grades, dates of attendance, grade point

average, degree / diploma certification, employment title, employment tenure, license attained, status of the

license, place of issue and any other information deemed necessary to conduct the verification of the

information / documentation provided.

I hereby release all persons or entities requesting or supplying such information from any liability arising from

such disclosure. I am willing that a photocopy of this authorization be accepted with the same authority as the

original. I further understand and acknowledge that this Information Release Form will remain valid for a period

of two years following its completion.

I confirm that all my certificates are affiliated and accredited from the issuing country

Personal Details:

(in BLOCK letters)

Full Name : _____________________________________________________________________ (Last/Surname) (First Name) (Middle Name)

Passport /Identity Card Number: _____________________________

_________________ ____________________Signature Date (dd/mm/yyyy)


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Applicant Name:

Document / Information Checklist (To be filled by the applicant)



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The following documents are mandatory. Please note that the request will not be processed if this information /

A Applicable to all

1 Application form duly filled in its entirety

2 Valid Passport Copies

3 Degree certificate copies (copy of original certificate(s)& translated copy)

4 Experience letters from previous employers for the last five years

5 Medical / Nursing license copy (front and back)

6 Valid Good Standing Certificate or equivalent

7 Payment receipt copy

B Applicable in special circumstances

1 Copy of the surgical log book (for surgeons only)

2 Mark sheet for the final year (all year mark sheets for applicants who have studied in India)

3Copy of the backside on the degree certificate ( for applicants having Afghanistan,Egyptian & Pakistani degrees/certificates)

4 Certificate of Authenticity and Verification (CAV) for applicants who have studied in Philippines

5 Name change certificate, if applicable (Marriage certificate, affidavit, any legal document, etc.)

For Official Use Only

Decision:

Approved As __________________________

Pending As __________________________

Rejected

Notes:

1. _______________________________________

2. _______________________________________

3. _______________________________________

4. _______________________________________

Credentialing:

_____________________ _________________ ____________Name Signature Date (dd/mm/yyyy)

Primary Source Verification (PSV): Basic Degree Professional licenseAdditional Degree Employment History

Applicant informed

_____________________ _________________ _____________Name Signature Date (dd/mm/yyyy)


Documents

Healthcare Professionals Application Form (1)