APPLICATION FOR A LICENSE TO PRACTICE AS A HEALTH PROFESSIONAL

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Linda Bryan
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1 Licensing & Registration Office National Health Regulatory Authority PO Box Manama Kingdom of Bahrain Please tick the relevant box: APPLICATION FOR A LICENSE TO PRACTICE AS A HEALTH PROFESSIONAL Application Number: (for official use only) Test Admission Number: (if applicable) Please attach 1 x passport-size photo here DOCTOR NURSE ALLIED (continued) Resident General Nurse Laboratory Technician Senior Resident Practical Nurse Laboratory Technologist Specialist Specialist Nurse Nuclear Medicine Technologist Consultant Midwife Nutritionist Optometrist/Optician DENTIST ALLIED Physiotherapist Resident Audiologist Prosthetist/Orthotist Senior Resident Dental Hygienist Radiographer Specialist Dental Technologist Radiologic Technologist Consultant Dietician Respiratory Therapist 1. PERSONAL DETAILS Full name (as it appears in passport): Previous name (if different from above): Address: ECG Technician Speech Therapist Other: (Please specify) Telephone Nos. (Mobile): Fax No.: CPR No.: Date of Birth: DD / MM / YYYY (Business): address: Passport No.: Country of Issue: Gender (please tick): Male Female Language Proficiency: Nationality: Arabic English Other (please specify): Prospective Employer/Sponsor: Address: Telephone Nos. (Mobile): Fax No.: (Business): address: L/APPL/Form (1) This form was last updated in August 2011 Page 1 of 5

Laboratory Technician Senior Resident Practical Nurse Laboratory Technologist Specialist Specialist Nurse Nuclear Medicine Technologist Consultant Midwife Nutritionist Optometrist/Optician DENTIST

2 NOTE: IF THIS FORM HAS BEEN PROVIDED TO YOU WITH AN APPLICATION NUMBER, PLEASE DO NOT PHOTOCOPY THIS FORM FOR USE BY ANOTHER APPLICANT L/APPL/Form (1) This form was last updated in August 2011 Page 2 of 5

3 2. PROFESSIONAL EDUCATION Please list in chronological order (starting with most recent) your professional education. Attach additional sheets if necessary. Name and address of University/Institution Program Year started Year completed Qualification or Degree obtained 3. LICENSURE IN OTHER COUNTRIES Please list ALL licenses which you hold or ever held in other countries. Country License Authority Type of License License Number Issue date Expiration Date L/APPL/Form (1) This form was last updated in August 2011 Page 3 of 5

Name and address of University/Institution Program Year started Year completed Qualification or Degree obtained 3.

4 4. WORK EXPERIENCE Please list in chronological order (starting with most recent) work experience you have obtained following completion of professional education, including internship training (where applicable). NOTE: Any absence from practise should be explained leave no gaps from graduation to present. Employer name and address Type: Government(G) Private(P) Other(O) Area of experience/ Specialty Position Held From MM / YY To MM / YY L/APPL/Form (1) This form was last updated in August 2011 Page 4 of 5

NOTE: Any absence from practise should be explained leave no gaps from graduation to present.

5 5. IMPORTANT QUESTIONS Please answer yes or no to each of the following questions by ticking the relevant box: YES 1. Has your registration/renewal certification/license to practise as a health professional ever been refused in any country/state/jurisdiction? 2. Has your registration/license to practise as a health professional ever been cancelled/ suspended/removed for any reason in any country/state/jurisdiction? 3. Have you ever had disciplinary action taken against your registration certification/license to practise as a health professional in any country/state/jurisdiction? 4. Have any conditions/restrictions ever been attached to your registration certification/ license to practise as a health professional in any country/state/jurisdiction? 5. Are there any special conditions/restrictions currently attached to your registration certification/license to practise as a health professional in any country/state/jurisdiction? 6. Do you know of any investigation pending against a registration certification/license to practise issued to you in any country/state/jurisdiction? 7. Have you ever been convicted of any criminal offence in any country/state/jurisdiction? NO 8. Are there any criminal investigations/charges pending against you in any country/state/ jurisdiction? 9. Do you have any health problem which in any way restricts your ability to practise as a health professional? *NOTE: If you have answered yes to any of the above questions, please attach a letter signed and dated by you, describing the circumstances.* 6. DECLARATION Please tick each box to indicate that you have read each sentence in this Declaration. I, the undersigned, certify that I am the person referred to in the foregoing application for registration in the Kingdom of Bahrain, and that the statements herein are true to the best of my knowledge, information and belief. I further affirm that I am of good physical and mental health and of good moral character and I will keep the Bahrain licensure authority informed of any criminal charges and/or physical or mental conditions which jeopardize the quality of care rendered by me to the public. I hereby authorize the Bahrain licensure authority to request any information, files or records to be released from relevant licensing authorities, educational facilities, and previous and past employers in connection with the processing of this application. I have carefully read the questions in the foregoing application and have answered them completely, without reservations of any kind and I declare under penalty of perjury that my answers and all statements made herein are true and correct. I understand that, should I furnish any false information in this application, such act shall constitute cause for denial, suspension or revocation of my license to practise in the Kingdom of Bahrain. Signature Date PLEASE DO NOT SUBMIT YOUR APPLICATION UNTIL YOU CAN ENCLOSE ALL REQUIRED DOCUMENTATION. 7. CHECKLIST Please use the checklist to make sure that you have attached all necessary documents. CPR/smart card* General education certificate (secondary school)** Front pages of passport Professional education certificate(s) 1 passport-size photograph Full Transcript of professional education Statutory evidence of any name change Registration/license in other country/ies (if licensed elsewhere) Health fitness certificate* CV Prospective employer letter Other: Please tick to confirm that Forms have been sent to the following with a request that they be sent directly to the NHRA: 2 x References++ (FORM 2) College/University++ (FORM 3) All relevant Licensing Authorities (FORM 4) * May be submitted on arrival in Bahrain ** Nurses/midwives only ++ For health professionals who obtained their degree outside Bahrain only L/APPL/Form (1) This form was last updated in August 2011 Page 5 of 5

Has your registration/license to practise as a health professional ever been cancelled/ suspended/removed for any reason in any country/state/jurisdiction? 3.

Application for Allied Health Professional License

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