Registration Application Form for Allied Health Professionals

RWANDA ALLIED HEALTH PROFESSIONS COUNCIL (RAHPC)
Application No:
No de demande
Registration Application Form for Allied Health Professionals
Formulaire de Demande d’Enregistrement des Professionnels de
santé alliés à la médecine
1: Identification
*First Name / Prénom : ………………………………………………….….……..
Middle Name / Deuxième Prénom :………………………….………………..…
*Last Name / Nom : ………………………………………………………….….…
Maiden Name/Nom de jeune fille : …………………………………………….…
Father's Name / Noms du Père :………………………………………………………………………
Mother's Name / Noms de la Mère :…………………………………………………………………….
I.D. Card / Carte d’identité
*Type of ID/ Pièce d'identité :
Passport / Passeport
*ID number/ N° de la Pièce d'identité :…………………………………………………………………
*Place of issue / Lieu de délivrance (District / Sector):………….….….. / ………….……….……
*Date of birth/Date de naissance (dd-mm-yyyy):
*2Photos
*Nationality / Nationalité :………………………………………………………………………………...
*Gender / Sexe :
F
M
2: Contact information/ Information de contact
*Country / Pays: ……………………..………………….……State / Etat: …………………………..
*Region/Province/City: ………..………………….…………………….………………………………
*District/ Commune /Town /Ville: …..……..….…..…….… *Sector/Secteur: ………….…..………
*Cell/Cellule/Localité :…………………………………….….*Village/ Village:………………………
*Street/Avenue/Rue :………………………………..………. House Nº / Maison Nº : ………………
*Po box / B.P…………………….
Town /Ville: ………………………..…………...…..
Mobile Phone/Tél Mobile:(Code)
+
Home Phone / Tél à Domicile :
+
Fax :
+
E-mail Address/ Adresse Electronique: .........................................................................................
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3: Education background / Etudes faites
Name of Secondary / Tertiary
training institution
Nom de l’Etablissement
secondaire et supérieur
/Universitaire
Country/
Pays
Course/
Section
Qualification
Niveau
(A2,
A1,A0,Maste
rs, PhD)
Date (dd-mm-yyyy)
From/ De
To/ A
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4: Additional training (from 3 months and above) / Formations
complémentaires (3 mois et plus)
Name of Training Institution
Nom de l’Etablissement
Country/
Pays
Course
Qualification
Niveau
Date (dd-mm-yyyy)
From/ De
.../…./….
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To/ A
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5- Working experience / experience professionnelle
5.1: Current situation/ situation actuelle
Institution and address/
Institution et adresse
Job Title/
Poste
CEO/ D.G/ Head of
Hospital/ Clinic
Date (dd-mm-yyyy)
From/ De
To/ A
…/…/…
…/…/…
.../…./…
.../…./….
.../…./…
.../…./….
5.2: Previous experience / Experience anterieure
Institution and address/
Institution et adresse
Job Title/
Poste
CEO/ D.G/ Head of
Hospital/ Clinic
Date (dd-mm-yyyy)
From/ De
To/ A
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6: Previous Registration/ Enregistrement anterieur
Council/ Conseil
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Country/
Pays
Professional
Title/ Title
Professionnel
Reg.
Number
Reg. Date
(dd-mm-yyyy)
Date (dd-mm-yyyy)
From/ De To/ A
.../…/…
…/…/…
.../.../…
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7: Professional Titles / Titres professionnels
Anesthesia practitioners
Nutrition practitioners
Biomedical laboratory practitioners
Ophthalmic practitioners
Clinical psychologists
Optometry clinical officers
Dental therapy practitioners
Orthotherapists
Environmental health practitioners
Physical therapy practitioners
Medical imaging practitioners
Prosthetists and Orthotists
Social Worker
Public Health Officers
Orthopedic Clinical Officers
Speech & Language Therapists
Occupational Therapists
Emergency Care Practitioners
Chiropractic Practitioners
Biomedical Equipment Engineers
Clinical Officers
Osteopathic Practitioners
Audiologists
Hearing instrument Dispenser
Other (Please Specify) …………………………………………………………………
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8: Signature
I authorize the Registrar to investigate and obtain from me, any person or any organization
such information as may be required in relation to this application. I certify that the statements
made by me in this application are true and complete. I am aware that misrepresentation or
falsification may result in rejection of my application or withdrawal of registration.
J'autorise le Registraire d'enquêter et d'obtenir de moi, toute personne ou toute organisation
telle que l'information peut être requise en ce qui concerne cette demande. Je certifie que les
déclarations faites par moi dans cette demande sont exacts et complets. Je suis conscient que
toute fausse déclaration ou falsification peut entraîner le rejet ou retrait de ma candidature.
Applicant Names
……………………………………..
Signature
Date
………………
9: For Office Use Only/ reservé au bureau:
Checklist
Application form
Copies of qualifications notified
Proof of payment
Copy of identity card or Valid Passport
2 Passport photos (3 x 3 cm)
Application Letter
Police clearance (Extrait du casier Judiciaire)
Employer’s Certificate for those who currently working / Attestation de service
Equivalence delivered by HEC for those who studied outside Rwanda
Decision
Application accepted/ acceptée
Application Rejected/rejetée
Reasons / Raison(s) avancée(s):
………………………………………..........................................................................…..
Type of registration/ Type d'enregistrement:
Full/Complet
Partial/Partiel
M.C number/ O.M numéro:
Signature and Stamp of the chairman/ Signature et cachet du president de NCB
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