Healthcare Professionals Application Form

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 to the Dubai Health Authority (DHA) for licensure?

□ No □x Yes

Please give detailsChief of Medical Department Alahli Club-Dubai 1997-2007

I am applying for: (please tick the appropriate category)

□x Physician or Dentist

□ Nurse & Midwife

□ Allied Health

□ Complementary Alternative Medicine (CAM)

I am applying for the professional license of:

For Official Use OnlyApproved Title :

_______________________________ Employing Facility

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

First name (given) Mircea

Middle name

Last name (family/surname) Miu

Maiden name (if applicable)

DOB: (dd/mm/yyyy) 09.03.1955 Place of Birth Racoviteni

Passport Number Nationality Roman

Date of Issue Date of Expiry

UAE National ID □x No □ Yes Number (if applicable)

Address in Home Country: Com.Brazi,Str.Fagului,Nr.8,Jud.Prahova

Address in UAE:(if different from above)

Email Address: [email protected] Tel. (business) 0040769061387

Tel. (residence) 0040724195545 Tel. (local UAE contact no)

www.dha.gov.ae [email protected] Page 1 of 8

Passport Size

Photograph

mailto:[email protected]

http://www.dha.gov.ae/

Section 3: Education Information- 1

Name as per Certificate (If certificate name is different than name as per passport, then please submit the relevant name change document)

University/Institution Name Medicine and Pharmacy University Bucharest

College Name

University Address. Bucharest, Romania

City Bucharest Area

University Country Romania Telephone No.

Qualification Attained (e.g. Doctor of Medicine)

Doctor of Medicine

Major Subject General Medicine Minor Subject Sport Medicine

Student Identity / Roll No.

Attendance PeriodFrom(dd/mm/yyyy)

1975 To (dd/mm/yyyy)

1981

Qualification Conferred Date (dd/mm/yyyy) 1981

Education Information – 2 (When applicable)

Name as per Certificate (If certificate name is different than name as per passport, then please submit the relevant name change 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 Period From(dd/mm/yyyy)

To (dd/mm/yyyy)

Qualification Conferred Date (dd/mm/yyyy)

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




Section 4: License InformationName as per License

Issuing Authority Name Medicine and Pharmacy University Bucharest

City Bucharest Area

Issuing Authority Country Romania Telephone No.

License Attained

License Type

License No.

Issue Period From(dd/mm/yyyy)

To (dd/mm/yyyy)

License Conferred Date (dd/mm/yyyy) 1981

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 Al Ahli Club-DubaiAddress DubaiWebsite address (URL)

Telephone NoEmploymentCode

Period of EmploymentFrom(dd/mm/yyyy)

1997 To (dd/mm/yyyy) 2007

Job Title / Designation Chief of Medical Department Department

Full time / Part time (If part time please specify the agency name if any)

Second Employer Details

Name of the Employer CSM FC Ploiesti Club (football & handball women)Address PloiestiWebsite address (URL)









Third Employer DetailsName of the Employer FCM Ploiesti ClubAddress PloiestiWebsite address (URL)






Fourth Employer Details

Name of the Employer FC Astra Ploiesti ClubAddress Str. Sondelor, PloiestiWebsite address (URL)






Fifth Employer Details

Name of the Employer FC Petrolul Ploiesti ClubAddress

Website address (URL)



2009 To (dd/mm/yyyy) Present






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 which may impair your ability to render professional services which are the subject of this 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 your clinical 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 in charges relating to moral or ethical turpitude? □ Yes □ No

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

7. Malpractice Insurance Coverage: Has there ever been any malpractice claims or lawsuits made against you alleging negligence or a treatment failure which has been pending, open or closed during any of your health professional practices?

□ 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 for the denial, or suspension or revocation of my license to practice?

Signature:

Date: 01.12.2010





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.

Personal Details:

(in BLOCK letters)

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

Passport /Identity Card Number: _____________________________

01.12.2010 _________________ ____________________ Signature Date (dd/mm/yyyy)



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

The following documents are mandatory. Please note that the request will not be processed if this information /documents are not provided. (Please provide clear and legible copies)

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 license Additional Degree Employment History

Applicant informed

_____________________ _________________ ____________________ Name Signature Date (dd/mm/yyyy)







Documents

Healthcare Professionals Application Form