NEW DENTAL & MEDICAL PRACTITIONERS – TEMPORARY APPLICATION

DENTAL & MEDICAL PRACTITIONERS – TEMPORARY APPLICATION

Attach additional documentation to this form though the upload feature at the end of the form, or email to janet@natuvu.org. Do not send documents to Fiji.
Year of Trip Registration
Do you wish to Practice?
1. PERSONAL INFORMATION
Last (Surname)
Current Reg. (License) No.
Sex
First (Forenames)
Country of Citizenship
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Other Names
Email
example@example.com
Residential Address
Telephone Mobile
Please enter a valid phone number.Format: (000) 000-0000.
Telephone Work
Please enter a valid phone number.Format: (000) 000-0000.
Postal Address
Passport Number
Language Spoken
Next of Kin
Next of Kin Relationship
Next of Kin Phone
Please enter a valid phone number.Format: (000) 000-0000.
Next of Kin Email
example@example.com
Next of Kin Address
2. MEDICAL OR DENTAL REGISTRATION HELD
If more than one, please attach page with additional registration details.
Date of Entry

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Reg. Authority
i.e. Medical Board of CA
Nation/State
i.e. USA/California
Valid Until
Enter Month & Year
General / Specialist
i.e. Physician / Surgeon
3. PRIMARY QUALIFICATION
Qualification Gained:
Ex: Physician
Institute:
Years & Length of Program:
Clinical Instruction Received at:
Language of Course:
4. REGISTRATION
Category of Registration: TEMPORARY (Enter clinic dates, not travel dates)
From

DayMonthYear
2 digit day, 2 digit month, 4 digit yearClinic Start Date
Until

DayMonthYear
2 digit day, 2 digit month, 4 digit yearClinic End Date
Reason for Seeking Registration

To provide free examinations and treatments to those in need, free of charge, at the Mission at Natuvu Creek, Buca Bay, Vanua Levu.
5. CONTINUING PROFESSIONAL DEVELOPMENT

List all CPD activities in the last 12 months. Use a separate page if needed.
Date (MM/YY)
Activity
Hours
Date (MM/YY)
Activity
Hours
Date (MM/YY)
Activity
Hours
6. PROFESSIONAL INDEMNITY
Do you have Professional Indemnity Insurance? YES

Details: Guernsey Trust International Helpers Insurance (See Attached) – Obtained by the Mission at Natuvu Creek
7. CRIMINAL / OTHER CONVICTIONS
Are you facing any criminal, drug, or alcohol related charges?
If yes, please provide details:
8. DECLARE INTEREST IN RELEVANT BUSINESS
Section 93 of the Medical & Dental Practitioner Act 2010 requires a registered person or close relative to declare interest in a relevant business. Please provide details:

No interest in a relevant business. Seeking temporary registration only to provide free humanitarian services at the Mission at Natuvu Creek in Vanua Levu.
9. DECLARATION BY APPLICANT
- I undertake to display my Annual Practice Certificate in the Public area of my Practice;
- I undertake to comply with all relevant legislation and Council guidelines, regulations, codes & standards;
- I undertake to provide the Council/Secretariat police clearance reports from all jurisdictions should the Council seek such documents;
- I undertake to provide the Council/Secretariat Dental reports or any report pertaining to the practice should the Council seek such documents;
- I undertake to inform the Council within 30 days should any of the details at any time change than that be stated on this form;
- I undertake to cooperate with the Council/Secretariat in all matters pertaining to complaints and disciplinary proceedings;
- I consent to the Secretariat to divulge relevant practice details as per the Medical & Dental Practitioner Act 2010;
- I declare that I am fit for practice in the vocation I am applying for;
- I make this declaration in the knowledge that a false statement may amount to perjury and revoke my Practicing Certificate;
- I solemnly declare to the best of my knowledge that all information provided is true and correct;
- I undertake to uphold the Medical / Dental profession in the highest esteem.
I have read and agree to the declaration above.
E-signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
PLACING YOUR NAME BELOW CONSTITUTES YOUR ELECTRONIC SIGNATURE
Name
Place
ATTACHMENTS - PLEASE UPLOAD DOCUMENTS
Head Shot Photo

Not more than 6 months old
Cancelof
Passport

Cancelof
Current License to Practice

Cancelof
University Degree

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Med or Dental School Degree

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Continuing Ed Certificates

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Additional Pages

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Should be Empty:

ATTACHMENTS - PLEASE UPLOAD DOCUMENTS