FILL OUT YOUR FORM Complete your form now, ensuring that all information is accurate : E-Doctors Form PERSONAL INFORMATION Team Member : SalmaAyaNagwaDr SherifNismaNardeenFatmaNo One Position : Years Of Experience : Basic Salary : Full Name : Full Name : First Name First Name Middle Name Middle Name Last Name Last Name Gender : Male Female Age : Personal Title : Mr Mrs Ms Contact Number : Viber No / WhatsApp No : Email : Date of Birth : SKYPE ID With Link : Passport Number : Passport Issued Date : Passport Expiry Date : Marital Status : Nationality : Number Of Dependents : Present Address : Building Name : Apartment / Floor No : City / State : Street : Country : Permanent Address : Building Name : Apartment / Floor No : City / State : Street : Country : EMERGENCY INFORMATION Emergency Contact Name : Relationship : Emergency Contact Address : Emergency Contact Number : EDUCATION PLEASE LIST THE HIGHEST QUALIFICATION Course Name : Start Date : End Date : Course Duration : Country : University / College : Course Name : Start Date : End Date : Course Duration : Country : University / College : Course Name : Start Date : End Date : Course Duration : Country : University / College : Course Name : Start Date : End Date : Course Duration : Country : University / College : OTHER TRAININGS Training : Name of Institution : Duration : Training : Name of Institution : Duration : Training : Name of Institution : Duration : Training : Name of Institution : Duration : INTERNSHIP Name of Institution : Start Date : End Date : Country : Name of Institution : Start Date : End Date : Country : Name of Institution : Start Date : End Date : Country : REGISTRATION Course Name : Name of the Council : Address of the council : Registration Date : Expiry Date : Registration Number : Course Name : Name of the Council : Name of the Council : Registration Date : Expiry Date : Registration Number : CURRENT & PREVIOUS EMPLOYMENT BEGIN FROM THE MOST RECENT Employer Name : Work Detail : Designation : Duration : Reason for leaving : Last Drawn Salary : Employer Name : Work Detail : Designation : Duration : Reason for leaving : Last Drawn Salary : Employer Name : Work Detail : Designation : Duration : Reason for leaving : Last Drawn Salary : Employer Name : Work Detail : Designation : Duration : Reason for leaving : Last Drawn Salary : RESIGNATION NOTICE * Notice period to be given to the current employer if the applicant is selected for the job : DOCUMENT CHECKLIST Completed Application Form Curriculum Vitae ( CV ) Copy of Passport Biodata Page ( Color Copy, with Minimum 1 Year Validity ) Copy of Academic Certificates Reference Letter (s) / Experience Letter (s) Passport size photo in official attire ( Color scanned - Soft Copy - Passport standard - 45mm x 35mm - white background ) Police Report (from expatriate’s home country) document must be in English and issued within the last 3 months from submission date Copy of valid registration and practicing license Certified English Language Certificate (O Level / A Level / IELTS / TEFL) Qualification certificate Specialization certificate Transcript & Mark sheets for both qualification & specialization certificate Internship certificate Basic registration certificate Specialist registration certificate Filled Pre-registration form ( Attached with the mail ) Good standing certificate ( which 3 Months gap shouldn’t be there from issue date to till now ) Visa Copy BACKGROUND CHECK 1. Have you got any friends or family working in Addu Equatorial Hospital ? Yes No If yes, please specify : 2. Have you got any friends or family working in ( ASMH ) Hospital ? Yes No If yes, please specify : 3. Have you got any friends or family working in Ministry of Health ? Yes No If yes, please specify : 4. Have you got any friends or family working in Gan Regional Hospital ? Yes No If yes, please specify : 5. Have you worked in Maldives before ? Yes No If yes, please specify : 6. Do you have any past or pending criminal conviction ? Yes No If yes, please specify : 7. Are taking treatment for any illness ? Yes No If yes, please specify : 8. Have taken treatment for any illness for more than 2 months ? Yes No If yes, please specify : 9. Have you applied your document through any agencies before ? Yes No If yes, please specify : 10. Are you pregnant ? Applicable only for females. Yes No If yes, please specify : 11- Is your cognitive, communicative, or physical capability to engage in the practice of medicine or surgery with reasonable skill and safety impaired or limited in any way ? Yes No 11a. If yes, are the limitations or impairments reduced or ameliorated because you receive ongoing treatment or participate in a monitoring program ? If yes Please describe. 11b. If yes, are the limitations or impairments reduced or ameliorated because of the field of practice, the setting, or the manner in which you have chosen to practice ? Please describe. 12- Are you engaged in any illegal use of controlled substances including the use of illegal substances or illegal use of legal controlled substances ? YES NO If yes, please specify : 13- Does your use of alcohol or chemical substance(s), including prescription medications, in any way impair or limit your ability to practice medicine with reasonable skill and safety ? YES NO 13 a - . If yes, have you taken any steps (i.e. treatment, psychotherapy, participation in a support group) to discontinue or reduce such use ? Please describe 14- Have you within the past five years been advised by your treating physician that you have a mental, physical, or emotional condition, which, if untreated, would be likely to impair your ability to practice medicine with reasonable skill and safety ? YES NO If “yes”, please answer the following : 14 a - With regard to any condition referenced above, are you being treated so that such impairment is avoided ? YES NO 14 b - With regard to any condition referenced above, are you in compliance with the recommended treatment ? YES NO 14 c - With regard to any condition referenced above, has your treating physician advised you that you are able to practice medicine with reasonable skill and safety ? YES NO 14 d - Identify your treating physician : 15 - Have you ever been denied a license by any medical council or licensing authority ? YES NO If, yes give particular : 16 - Has your license to practice medicine been revoked, suspended, restricted ,or conditioned by a Medical council or other licensing authority ? YES NO If so, give particulars : 17 - Have you ever been notified of any investigation by any medical council, or any hospital of any complaints against you relative to the practice of medicine ? YES NO If so, give particulars : 18 - Have you ever been a defendant in any malpractice lawsuit, had any malpractice settlement, or have any pending ? YES NO If yes, give details : 19 - Have there ever been any criminal charges filed against you? This includes charges of disorderly conduct, assault or battery or domestic abuse YES NO 20 - Reason for late renewal, if applying past the expiry date : DISCLAIMER ِApplicant Name : Date : Sign : Clear UPLOAD DOCUMENTS If you are a General Practitioner , you don't have to upload the following : Specialist Qualifications , Specialist Registration and Specialist Academic Transcript MBBS Qualification Certificate : Click to upload Choose File Maximum file size: 5MB Internship : Click to upload Choose File Maximum file size: 5MB Academic Transcript : Click to upload Choose File Maximum file size: 5MB Passport Copy : Click to upload Choose File Maximum file size: 5MB English language Competency : Click to upload Choose File Maximum file size: 5MB Basic Registration : Click to upload Choose File Maximum file size: 5MB Experience Certificate : Click to upload Choose File Maximum file size: 5MB Police Clearance Certificate : Click to upload Choose File Maximum file size: 5MB CV : Click to upload Choose File Maximum file size: 5MB Secondary School Certificate : Click to upload Choose File Maximum file size: 5MB Specialist Qualification : Click to upload Choose File Maximum file size: 5MB Specialist Registration : Click to upload Choose File Maximum file size: 5MB Specialist Academic Transcript : Click to upload Choose File Maximum file size: 5MB Date Submit If you are human, leave this field blank.
