Borang Pendaftaran AMOTeX

SENARAI SEMAK
Sila tandakan (√) pada yang berkenaan

1. Borang permohonan AMOTeX APPLICATION FORM

yang lengkap perlu ditandatangan oleh Ketua Penyelia dan Ketua Jabatan
Klinikal / Pakar Kesihatan Keluarga

2. Salinan Perakuan Pembaharuan Tahunan (PPT) Penolong Pegawai

Perubatan yang disahkan (tahun semasa)

3. Salinan Sijil Perakuan Pendaftaran Pembantu Perubatan yang disahkan

4. Salinan sijil Credentialing terkini yang disahkan

5. Salinan sijil Pos Basik (PB)/Diploma Lanjutan/Kursus yang berkaitan

ATAU syarat pilihan (buku log bagi tiga bidang yang tiada PB (Kesihatan Awam)
/latihan lanjutan yang disahkan.

Semua borang dan salinan sijil hendaklah dihantar dalam satu salinan sahaja

Alamat Penghantaran Borang Permohonan :

KETUA PENOLONG PEGAWAI PERUBATAN

CAWANGAN PERKHIDMATAN PENOLONG PEGAWAI PERUBATAN
BAHAGIAN AMALAN PERUBATAN
KEMENTERIAN KESIHATAN MALAYSIA
ARAS 6, BLOK E1, KOMPLEKS E,
PUSAT PENTADBIRAN KERAJAAN PERSEKUTUAN
62590 PUTRAJAYA
WILAYAH PERSEKUTUAN PUTRAJAYA

Tel : 03 8883 1370

Faks : 03 8883 1490

Di semak oleh: .............................................

(Tandatangan & Cop Penyelia)
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 AMOTeX APPLICATION FORM

HOSPITAL / DISTRICT HEALTH OFFICE (PKD) : .....................................................

DATE OF APPLICATION : ................................................................................................

1. PERSONAL DETAILS

1.1 Name : ...........................................................................................................................

1.2 I/C Number : ....................................................................................................................

1.3 Office Address : .......................................................................................................

.......................................................................................................

.......................................................................................................

.......................................................................................................

1.4 Area/ Discipline/ Specialty: ............................................................................................

1.5 Telephone Number: Office : ...................................................

Mobile : ...................................................

1.6 Email Address : ………………………………………………….......................................

1.7 Date of first appointment : .................... ...................... (DD/MM/YY)

1.8 Duration of service: .......................years

1.9 Date of Full Registration with Medical Assistant Board : ……………………….

1.10 Current Annual Renewal Certificate No.: ………………………………….

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2. PROFESSIONAL QUALIFICATIONS

Diploma / Degree / Masters/ etc. University/ College Year of qualification

(Please attach certified copies of degree /diploma /certificate with the form)

3. POST BASIC TRAINING / RELATED COURSES

Duration Year
Type of Training Institution (Qualified)
(month)

(Please attach certified copies of certificates obtained, Please use attachment sheet if space

inadequate)

4. WORKING EXPERIENCE

Discipline Place dd/mm/yy Duration

(from – till)

(Use attachment sheet if space inadequate)

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 5. AMOTeX APPLIED

Cardiology Neurosurgery
Cardiology Perfusion Obstetrics & Gynecology
Cardiothoracic Surgery Oncology
Emergency Medicine & Trauma Services Otorhinolaryngology
Nephrology Ophthalmology
Orthopaedic Plastic & Reconstructive Surgery
Neurophysiology Pre Hospital & Ambulance Services
Diabetes Psychiatry & Mental Health
HIV/AIDS Counseling Radiotherapy & Oncology
Wound Care Management Respiratory
Anesthesiology & Intensive Care Urology
Endoscopy Adolescent Health Programs
Forensic Medicine Elderly Health Programs
Nuclear Medicine Epidemiology
Hand & Microsurgery Men’s Health Programs
Infection Control Primary Health Care
Intensive Care TB/Leprosy

*Please do not tick ( √ ) on the black box. Only applicable for the 2nd phase of AMOTeX

6. NAME OF TWO REFEREES

NAME POSITION PLACE OF WORK

I hereby declare that all the information given above are true and correct.

Signature of applicant : ……………………..............

Date : …………………..............
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7. APPLICANT APPRAISAL [to be filled by AMO Supervisor (Department/unit)]

7.1 I have known the applicant for ............................. (duration)

7.2 I recommend / do not recommend the applicant for AMOTeX registration in the field
requested.
(delete where applicable)

………………………………….

Signature Official

Stamp :

Contact No :

Date :

8. APPLICATION APPROVAL [By Head of Department (Clinical) / FMS]

......................................... is approved / not approved for submission to the AMOTeX

Assessment Committee.

............................................. Date : ...........................................

Signature

Official stamp :
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FOR OFFICIAL USE

AMOTEX ASSESSMENT COMMITTEE DECISION

Application Approved

For Reassessment*

Application Rejected*

*Reasons:

………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………

AMOTeX Assessment Committee Chairman.

………………………… Date……………………
Signature

The above decision will be brought to the next Medical Assistant Board (MAB) meeting for endorsement

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