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HEALTH - Application Form Internship

This document is an application form for registration with the Bahamas Medical Council. It requests information such as the applicant's name, date and place of birth, nationality, contact information, citizenship documentation, medical degree details, additional qualifications, references, and a declaration that the applicant can communicate in English and that the information provided is true. The form notes that any changes to the documentation must be promptly notified to the Council.

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Anastasiafynn
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© Attribution Non-Commercial (BY-NC)
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15 views

HEALTH - Application Form Internship

This document is an application form for registration with the Bahamas Medical Council. It requests information such as the applicant's name, date and place of birth, nationality, contact information, citizenship documentation, medical degree details, additional qualifications, references, and a declaration that the applicant can communicate in English and that the information provided is true. The form notes that any changes to the documentation must be promptly notified to the Council.

Uploaded by

Anastasiafynn
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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BAHAMAS MEDICAL COUNCIL


Application Form for Registration under Section 13b

Name:________________________________________________________________
(Surname)
(First Name)
Date and Place of Birth:___________________________________________________
Nationality:
Telephone: (Home)

Age:

Sex:
(Work)

Marital Status:___________
(Cell)_______________

Email Address:___________________________________________________________
Postal Address: (Home)____________________________________________________
Postal Address: (Work) ____________________________________________________
Name, Postal Address & Telephone Number of a local contact person:
________________________________________________________________________
________________________________________________________________________
1. Document certifying citizenship (passport, birth certificate or affidavit)
2. Medical Degree, Name & Place of the Medical School, Date Degree Obtained.
(Enclose original diploma or notarized copy):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
3. List of Additional and/or Higher Qualifications - full particulars and dates.
(Enclose original diplomas or notarized copies):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. Include Employee Contract or Employment Intention Letter

PLEASE TURN OVER

5. Have any proceedings ever been initiated against you in a court of law or by a
medical licensing authority? (Yes or No,
if yes provide details):
__________________________________________________________________
__________________________________________________________________
6. State type of practice you wish to pursue: Internship

7. Professional References: Include 3 current testimonials with full postal address:


__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
I declare that I can read, write, speak and understand the English Language, and that
the information contained in this application is true and correct. Should any changes
occur in the documentation presented with my application I shall promptly notify the
Council of the changes.

Signature of Applicant:_____________________
Date: ____________________________________

BAHAMAS MEDICAL COUNCIL


Mailing Address:

79 Collins Ave
2nd Floor
P.O. Box N-9802
Nassau, Bahamas
Telephone No:
(242) 323-0342/ 3
Fax No:
(242) 323-0344
Office Hours:
Mondays - Friday
9:00am 5:00 pm

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