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! DataFlow Application Form
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ONLY TYPED FORMS IN ENGLISH WILL BE ACCEPTED
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Verification program - Registration Department – Qatar Council for Healthcare Practitioners –023+,
Qatar.
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Personal Details: Please give your name in full (as per your Passport/ National ID) and alternatives where
applicable.
Maiden Name (i.e. Family Name / Last / Surname before marriage) should be provided where appropriate.
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(FORM TO BE FILLED IN BLOCK / CAPITAL LETTERS ONLY)
* Family Name (Last / Surname)

* Given Name (First Name)

* Middle Name

Maiden Name (If Applicable)

* Date of Birth (dd/mm/yyyy) Place of Birth

* Passport No. * Nationality

National Identity Card No. * Gender Male Female

* Visa Type Visit Resident

* Mailing Address in Qatar

City * Post Code

Area Country

Tel. No. in Qatar (Mobile / Res)

Email Address

* Current / Potential place

of work in the State of Qatar
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Educational Qualifications and license information: Please provide full and clear name and address for the
institution attended. Indicate clearly your qualification and the exact name and address of the qualifying
body. Do not use abbreviated terms or initials.
!
Please provide FULL details of your highest degree / diploma level qualification as follows
!

Application For : Physician Dentist Nursing Allied Health Pharmacist

Complimentary Medicine
  
 
 
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  

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.  

Seat No. / Registration No.  

Attendance Period From (dd/mm/yyyy)   To (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 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.  

Seat No. / Registration No.  

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

 
 
* Qualification Conferred Date (dd/mm/yyyy)
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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)

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Experience Details
Please provide full details of previous employers for the last 5 years for physicians & 3 years for the others; starting in order from latest to the
previous employer.

1st Employer Details

* Name of the Employer
* Address
* Website address (URL)
* Telephone No Employment Code

* Period of Employment From (dd/mm/yyyy) To (dd/mm/yyyy)

* Job Title / Designation Department

* Full time / Temporary Full time Temporary

If temporary please specify the agency name if any

2nd Employer Details

* Name of the Employer
* Address
* Website address (URL)
* Telephone No Employment Code

* Period of Employment From (dd/mm/yyyy) To (dd/mm/yyyy)

* Job Title / Designation Department

* Full time / Temporary Full time Temporary

If temporary please specify the agency name if any
  

 
 
 
 
 
 
3rd Employer Details  

* Name of the Employer  

* Address  

* Website address (URL)  

 

* Telephone No   Employment Code  

   

* Period of Employment From (dd/mm/yyyy)   To (dd/mm/yyyy)  

 

* Job Title / Designation   Department  

   
   
* Full time / Temporary Full time Temporary
If temporary please specify the agency name if any

4th Employer Details  

* Name of the Employer  

* Address  

* Website address (URL)  

 

* Telephone No   Employment Code  

   

* Period of Employment From (dd/mm/yyyy)   To (dd/mm/yyyy)  

 

* Job Title / Designation   Department  

   
   
* Full time / Temporary Full time Temporary
If temporary please specify the agency name if any

5th Employer Details  

* Name of the Employer  

* Address  

* Website address (URL)  

 

* Telephone No   Employment Code  

   

* Period of Employment From (dd/mm/yyyy)   To (dd/mm/yyyy)  

 

* Job Title / Designation   Department  

     
   
* Full time / Temporary Full time Temporary  
temporary please specify the agency name if any
 Letter of Authorization ‫ﺧﻄﺎب اﻟﺘﻔﻮﻳﺾ‬

I hereby authorize DataFlow, its authorized affiliates, ‫ و ﻣــﻦ ﺗﻔﻮﺿــﻪ‬،‫اﻧــﺎ اﻟﻤﻮﻗــﻊ ادﻧــﺎه اﻓــﻮض ﺷــﺮ ﻛــﺔ داﺗـﺎﻓﻠـــﻮ‬
agents and subsidiaries, acting on its behalf to verify ‫ ﻟﻠﺘﺤﻘــﻖ ﻧﻴﺎﺑــﺔ ﻋﻨــﻲ ﻓــﻲ اﻟﻤﻌﻠﻮﻣــﺎت و اﻟﻮﺛﺎﺋــﻖ‬،€‫رﺳــﻤﻴ‬
information, documentation presented with my ‫ و‬،‫اﻟﻤﺮﻓﻘــﺔ ﺑﻄﻠﺒــﻲ ﺑﻤــﺎ ﻓــﻲ ذﻟــﻚ اﻟﺸــﻬﺎدات اﻟﻌﻠﻤﻴــﺔ‬
application form including education, employment and ‫اﻟﺨﺒــﺮات اﻟﻮﻇﻴﻔﻴــﺔ و اﻟﺮﺧــﺺ اﻟﻤﻬﻨﻴــﺔ ﻣــﻦ اﻟﺠﻬــﺎت اﻟﻤﺼــﺪرة‬
professional licenses .‫ﻟﻬﺬه اﻟﻮﺛﺎﺋﻖ واﻟﺸﻬﺎدات‬
.
I hereby grant the authority for the bearer of this letter, ‫ أﻣﻨــﺢ اﻟﺤــﻖ ﻟﺤﺎﻣﻠــﻲ ﻫــﺬا اﻟﺨﻄــﺎب‬،‫و ﺑﻤﻮﺟــﺐ ﻫــﺬا اﻟﺘﻔﻮﻳــﺾ‬
with immediate effect to release all necessary ، ‫ﺗﺴــﻠﻴﻢ ﺟﻤﻴــﻊ اﻟﻤﻌﻠﻮﻣــﺎت اﻟﺨﺎﺻــﺔ ﺑــﻲ ﻟﺸــﺮ ﻛــﺔ داﺗـﺎﻓﻠـــﻮ‬
information to the DataFlow, its authorized affiliates, .‫وﻣﻦ ﺗﻔﻮﺿﻪ رﺳﻤﻴ€ ﻟﺬﻟﻚ‬
agents and subsidiaries
. ‫و ﺗﺸــﻤﻞ ﻫــﺬه اﻟﻤﻌﻠﻮﻣــﺎت و اﻟﻮﺛﺎﺋــﻖ اﻟﻤﻄﻠﻮﺑــﺔ ﻋﻠــﻰ ﺳــﺒﻴﻞ‬
This information / documentation may contain but is not ‫ و‬،‫ و اﻟﻤﻌــﺪل اﻟﺘﺮاﻛﻤــﻲ‬،‫اﻟﻤﺜــﺎل ﻻ اﻟﺤﺼــﺮ ﻋﻠــﻰ ﺗﻮارﻳــﺦ اﻟﺪراﺳــﺔ‬
limited to grades, dates of attendance, grade point ‫ و ﻣــﺪة‬،‫ و اﻟﻤﺴــﻤﻰ اﻟﻮﻇﻴﻔــﻲ‬،‫اﻟﺪرﺟــﺔ أو اﻟﺸــﻬﺎدة اﻟﻌﻤﻠﻴــﺔ‬
average, degree / diploma certification, employment ‫ و ﻣــﻜﺎن‬،‫ و ﺣﺎﻟــﺔ اﻟﺘﺮﺧﻴــﺺ‬،‫ و اﻟﺘﺮﺧﻴــﺺ اﻟﻤﻬﻨــﻲ‬،‫اﻟﺨﺪﻣــﺔ‬
title, employment tenure, license attained, status of the ‫ و أﻳــﺔ ﻣﻌﻠﻮﻣــﺎت أﺧــﺮى ﺿﺮورﻳــﺔ ®ﺟــﺮاءات اﻟﺘﺤﻘــﻖ‬،‫ا®ﺻــﺪار‬
license, place of issue and any other information .‫ﻣﻦ اﻟﻤﻌﻠﻮﻣﺎت و اﻟﻮﺛﺎﺋﻖ اﻟﻤﻘﺪﻣﺔ ﻣﻦ ﻗﺒﻠﻲ‬
deemed necessary to conduct the verification of the
information / documentation provided ‫ﺷــﺨﺎص أو اﻟﺠﻬــﺎت‬±‫و أﻗــﺮ ﺑــﺄن أﺧﻠــﻲ ﻣﺴــﺆوﻟﻴﺔ ﺟﻤﻴــﻊ ا‬
. ‫اﻟﻄﺎﻟﺒــﺔ ﻟﻬــﺬه اﻟﻤﻌﻠﻮﻣــﺎت ﻣــﻦ أي ﻣﺴــﺆوﻟﻴﺔ ﻗﺎﻧﻮﻧﻴــﺔ ﻗــﺪ‬
I hereby release all persons or entities requesting or ‫ و أواﻓــﻖ ﻋﻠــﻰ أن ﺗﻜــﻮن ﺻــﻮرة ﻫــﺬا اﻟﺨﻄــﺎب‬.‫ﺗﻨﺸــﺄ ﻋــﻦ ذﻟــﻚ‬
supplying such information from any liability arising from .‫ﺻﻞ‬±‫ﻣﺜﻞ ا‬
such disclosure. I confirm and acknowledge that a
photocopy of this authorization be accepted with the ‫ﻛﻤــﺎ أﻓــﻮض ﻣﺴــﺘﻠﻢ اﻟﻤﻌﻠﻮﻣــﺎت اﻟﻜﺸــﻒ ﻋــﻦ ﻫــﺬه‬
.same authority as the original .‫اﻟﻤﻌﻠﻮﻣﺎت إﻟﻰ أي ﻃﺮف ﺛﺎﻟﺚ ذات ﻋﻼﻗﺔ‬
I acknowledge the right for the Information Recipient to ‫أﻗــﺮ ﺑﺄﻧﻨــﻲ ﻗــﺪ ﻗــﺮأت ﺧﻄــﺎب اﻟﺘﻔﻮﻳــﺾ وﺑﻬــﺬا اواﻓــﻖ ﻋﻠــﻰ ان‬
disclose my information to a third party ‫ﻳﺘــﻢ ﺟﻤــﻊ واﺳــﺘﺨﺪام وﻣﻌﺎﻟﺠــﺔ وﻧﻘــﻞ اﻟﺒﻴﺎﻧــﺎت اﻟﺨﺎﺻــﺔ ﺑــﻲ‬
. ‫وﻓﻘــﺎ ﻟﺴﻴﺎﺳــﺔ اﻟﺨﺼﻮﺻﻴــﺔ اﻟﻤﺘﻌﻠﻘــﺔ ﺑﻤﻘﺪﻣﻴــﻦ اﻟﻄﻠﺒــﺎت و‬
I acknowledge that I have read and hereby agree to ‫اﻟﺘــﻲ ﻳﻮﺟــﺪ ﻣﻨﻬــﺎ ﻧﺴــﺨﺔ ﻣﺘﺎﺣــﺔ ﻋﻠــﻰ اﻟﻤﻮﻗــﻊ ا®ﻟﻜﺘﺮوﻧــﻲ و‬
the collection, use, processing and transfer of data ‫ﺧﻄﺎب اﻟﺘﻔﻮﻳﺾ‬
about me in accordance with the DataFlow Applicant
Privacy Policy, a copy of which is available on the (www.dataflowgroup.com/applicant-privacy-policy)
Dataflow Group website and this Letter of Authorization

(www.dataflowgroup.com/applicant-privacy-policy)
Personal Details:
(in BLOCK letters)

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

Passport / Identity Card Number:

Signature Date (dd/mm/yyyy)

 Document / Information Checklist

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 of the documents Submitted
indicating the University logo)

1 Application form duly filled in its entirety including the signed letter of authorization

2 Valid Passport Copies

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

Basic degree certificate copy + high degree certificate for physicians & dentists if applicaple.
4
(copy(s) of the original certificate(s) & translated copy to English or Arabic

Certificate of Authenticity and Verification (CAV) certificate (for applicants who have studied in
5
Philippines)

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

Copy of the backside on the degree certificate ( for applicants having Afghanistan, Egyptian &
7
Pakistani degrees/certificates)

8 Experience letters from previous employers for the last 5 years for physicians & 3 years for the others

9 License copy from the latest place of work (front & back)

10 Payment receipt copy

11 Qatari License copy in case of Uetrospective