Transcription of APPLICATION FOR RENEWAL OF LICENSE TO PRACTICE AS A …
1 Healthcare Professions Division Tel : +973 17 11 33 29 eMail : Website : Box : 11464, Manama, Kingdom of Bahrain Form 6: APPLICATION for RENEWAL of professional LICENSE For office use: APPLICATION number: APPLICATION FOR RENEWAL OF LICENSE TO PRACTICE AS A HEALTH PROFESSIONAL Part I- To be completed by the applicant _____ LICENSE / Registration Number Expiry Date of Current/Last LICENSE Profession: (Please tick one) Doctor General Specialist Consultant Dentist General Specialist Consultant Nurse General nurse Practical nurse Specialist nurse Midwife Allied Dental hygienist Dietician ECG technician Laboratory Medical Representative Allied (cont.) Nuclear medicine technician Optometrist Pharmacist Pharmacy technician Physiotherapist Prosthetist Public health inspector Radiographer Respiratory technician Speech/Audio therapist Specialty (please specify if applicable)_____ Type of Employment Full Time Part Time 1.
2 Personal details Full name (as it appears on Passport) _____ CPR number_____ Postal address_____ _____ Work Tel Mobile E-mail_____ 2. Employment details Please list all work experience you have obtained since your last LICENSE RENEWAL : Experience Facility name and address Type (Hospital, center, polyclinic) Position held Area of PRACTICE From To M/Y M/Y 3. Education Formal qualifications obtained since last RENEWAL Please list any new formal healthcare qualifications you have obtained since your last RENEWAL . Attach certified copies of transcript. Program Qualifications received Institution Date entered Date completed Country Tick here if you believe your qualification entitles you to a new LICENSE type and are applying to have your LICENSE type reviewed by the NHRA. Specify new LICENSE type applied for: _____ 4.
3 Declaration I hereby declare that: 1) I have no health condition(s) that may affect my fitness to practise my profession. 2) I have not been convicted of a crime, nor are there any criminal charges pending against me. 3) I know of no other reason that the NHRA may consider me unfit or unsuitable to practise my profession. 4) All information submitted in this form is correct and truthful to the best of my knowledge. _____ _____ Applicant signature Date In accordance with the law in Bahrain (decree of 1989 for Physicians and Dentists, decree no. 2 of 1987 for Nursing and Allied health professions, decree & 97 for pharmacologist you are requested to notify the NHRA whenever you change your name, home address, or your place of PRACTICE .
4 Part 2 To be completed by the applicant s employer Employer s Name:_____ Facility Name: _____ Facility LICENSE Job title in Facility: _____ Tel: _____ Email: _____ I confirm that the above applicant continues to be employed by this facility as a healthcare professional, and that the applicant only undertakes healthcare tasks that are appropriate for their profession, qualification and skill level. Signed: _____ Date: _____ Official seal.
