APPLICATION FOR RENEWAL OF REGISTRATION by 00Q4hcA

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									                                                      Fiji Medical Council
                      APPLICATION FOR RENEWAL OF TEMPORARY REGISTRATION
For Visiting Practitioners not normally resident in Fiji, for approved, specified, short-term projects,
who have previously been granted temporary registration by the Fiji Medical Council, in Part II of the register, and including those also
registered as Specialists, who have already filed a full (2007 version) application form, and supporting documents.
         All applications must be accompanied by letter(s) of recommendation from approved local, medically-qualified sponsors, who will be
          responsible for the organization of the project, and compliance with Ministry of Health guidelines for visiting practitioners

Name
            Surname                                             Given names                                                   ______________+


Date of Application: (d) _______/(m)_________ 20                       _____
                                                                                                             o
                                                                                              FMC File N
Year of first registration in Fiji: _______________________

Latest Certificate of Registration in Fiji issued on ________   /______ /20______                     ,

Last period of Medical Practice in Fiji (mo/yr)         /           Duration :       weeks        Location   ……………………………….

1.          Reason for seeking renewal of registration:

     Dates of proposed visit:         From (d)_____/(m)____/20_____           , Until (d)_____/(m)_______/20_______

     Nature of Proposed Services:

     Location of proposed activity(s):

     Identity, address, & of local sponsor

  Note: The local sponsor, who must be identified for medicolegal reasons, must be either the Medical Director/Superintendent of an
    established, registered medical facility, or a well-established local medical practitioner in a field relevant to the nature of the project.
_________________________________________________________________________________________________________________
2. Give full details of any change in the nature, scope, or location of your medical practice, including employment, service obligations &
    hospital appointments, subsequent to your last period of practice in Fiji:




________________________________________________________________________________________________________________
3. Give full details of any change in your registration status (including new registrations, or pending Enquiries), since your last period of
    medical practice in Fiji:




Declaration by Applicant:
    1. I declare that the information given in this application is true and accurate; and that I have not concealed any relevant information
         from the Fiji Medical Council.
    2. I further declare that, while in Fiji, I will comply with all relevant laws and statutes of Fiji, and not commit any professional
         misconduct.
    3. I understand that if I am found to have made any false statement to the Fiji Medical Council, my application will be unsuccessful,
         and this fact may be entered against my name in the database of the Fiji Medical Council, and be notified to the Medical
         Registration Authority of the nation / state where I am currently practising.


Signed ______________________________________________________     Date _______/_________/.20________
___________________________________________________________________________________________________________
Documents Required:
        If you have changed your name, eg at marriage, supply a copy of your marriage certificate
       1.
        If you have changed your citizenship, give a copy of naturalization certificate / passport ID page
       2.
        If you have become registered with a new authority, give a copy of your Certificate of Registration
       3.
        In every case, a Certificate of Good Standing, dated within the preceding 12 months must be provided; together
       4.
        with a current practising certificate, from your country of normal residence (such as is available from the NZMC website), dated within
        he preceding 3 months
_______________________________________________________________________________________________________
             Fiji Medical Council,                                     Tel:     (679) 3221 504, (679) 3221 409
             PO Box 2223,                                              Fax:     (679) 3312 483
             Government Buildings, SUVA                                email: medical.council@health.gov.fj

								
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