Professional Documents
Culture Documents
Photograph
Please complete this application on the computer then print and sign. Hand-written applications will not be accepted.
No
No Yes
065301191
0509501247
www.dha.gov.ae
regulation@dha.gov.ae
Page 1 of 7
(If certificate name is different than name as per passport, then please submit the relevant name change document)
Minor Subject
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regulation@dha.gov.ae
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To (dd/mm/yyyy)
First Employer Details Name of the Employer Address Website address (URL) Telephone No Period of Employment Job Title / Designation Full time / Part time Second Employer Details Name of the Employer Address Website address (URL) Telephone No Period of Employment Job Title / Designation Full time / Part time From
(dd/mm/yyyy)
From
(dd/mm/yyyy)
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regulation@dha.gov.ae
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Third Employer Details Name of the Employer Address Website address (URL) Telephone No Period of Employment Job Title / Designation Full time / Part time Fourth Employer Details Name of the Employer Address Website address (URL) Telephone No Period of Employment Job Title / Designation Full time / Part time Fifth Employer Details Name of the Employer Address Website address (URL) Telephone No Period of Employment Job Title / Designation Full time / Part time From
(dd/mm/yyyy) Employment Code
From
(dd/mm/yyyy)
To (dd/mm/yyyy)
Department
From
(dd/mm/yyyy)
www.dha.gov.ae
regulation@dha.gov.ae
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2. License: Has your professional license in any country ever been suspended,
I hereby grant the authority for the bearer of this letter, with immediate effect, to release all necessary Yes No informationor placed on a conditional status? revoked to the Dubai Health Authority or DataFlow FZ LLC, its authorized affiliates, agents and subsidiaries.
3.This informationthere any formal investigation pending against you to this time? License: Are / documentation may contain but is not limited at grades, dates of attendance, grade point Yes No
average, degree / diploma certification, employment title, employment tenure, license attained, status of the
4.license, place of issueHave you ever voluntarily surrendered or necessary to conduct the verification of the Hospital Sanctions: and any other information deemed diminished your Yes No
clinical privileges pending an investigation that may have lead to censure, information / documentation revocation of such privileges? restriction, suspension or provided.
Yes No I hereby release all persons or entities requesting or supplying such information from any liability arising from charges relating to moral or ethical turpitude? such disclosure. I am willing that a photocopy of this authorization be accepted with the same authority as the 6.original. I further understand and acknowledge that this Information Release Form will remain valid for a period Disciplinary Actions: Have you ever been the subject of disciplinary Yes No proceedings by any professional association or organisation of two years following its completion.
7. Malpractice Insurance Coverage: Has there ever been any malpractice claims
or lawsuits made against you alleging negligence or a treatment failure which Personal Details: has been pending, open or closed during any of your health professional (inpractices? BLOCK letters)
Yes
No
If you answered yes to any of the above questions; please explain: Full Name : _____________________________________________________________________ (Last/Surname) (First Name) (Middle Name)
I hereby affirm by my signature, that the information I have completed under penalty of perjury is true and correct. Should I furnish any false information in this application I hereby agree that such an act shall constitute cause for the denial, or suspension or revocation of my license to practice? Signature: _________________ Signature Date: ____________________ Date (dd/mm/yyyy)
www.dha.gov.ae
regulation@dha.gov.ae
Page 5 of 7
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regulation@dha.gov.ae
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A
1 2 3 4 5 6 7
Applicable to all
Application form duly filled in its entirety Valid Passport Copies Degree certificate copies (copy of original certificate(s)& translated copy) Experience letters from previous employers for the last five years Medical / Nursing license copy (front and back) Valid Good Standing Certificate or equivalent Payment receipt copy
B
1 2 3 4 5
Pending As __________________________
Rejected
Credentialing: _____________________ Name Primary Source Verification (PSV): Applicant informed _____________________ Name _________________ Signature ____________________ Date (dd/mm/yyyy) _________________ Signature Basic Degree Additional Degree ____________________ Date (dd/mm/yyyy) Professional license Employment History
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