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Complete your form now, ensuring that all information is accurate :

E-Doctors Form

PERSONAL INFORMATION

Team Member : * Team Member :

Position : *

Job title المسمى الوظيفي

Years Of Experience :

Basic Salary :

Full Name : *

Full Name :

First Name

Middle 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 :

No. of family members عدد أفراد الأسرة

Present Address :
العنــــوان الحــــالــي

Building Name : *

Apartment / Floor No : *

City / State : *

Street : *

Country : *

Permanent Address :
العنـوان الـدائـــم

Building Name : *

Apartment / Floor No : *

City / State : *

Street : *

Country : *

EMERGENCY INFORMATION

بيانات شخص ذو صلة بك في حالة الطوارىء

Emergency Contact Name : *

الاسم

Relationship : *

صلة القرابة

Emergency Contact Address : *

العنوان

Emergency Contact Number : *

رقم الهاتف

EDUCATION

PLEASE LIST THE HIGHESالT QUALIFICATION

المؤهلات العلمية من الاحدث للأقدم

Academic Degree : *

اسم المؤهل العلمي

Start Date :

End Date :

Course Duration : *

Country : *

University / College : *

Academic Degree :

اسم المؤهل العلمي

Start Date :

End Date :

Course Duration :

Country :

University / College :

Academic Degree :

اسم المؤهل العلمي

Start Date :

End Date :

Course Duration :

Country :

University / College :

Academic Degree :

اسم المؤهل العلمي

Start Date :

End Date :

Course Duration :

Country :

University / College :

OTHER TRAININGS

دورات أو تدريبات إضافية

Training :

اسم التدريب

Name of Institution :

اسم مكان التدريب

Duration :

مدة التدريب

Training :

اسم التدريب

Name of Institution :

اسم مكان التدريب

Duration :

مدة التدريب

Training :

اسم التدريب

Name of Institution :

اسم مكان التدريب

Duration :

مدة التدريب

INTERNSHIP

الامتيــــــــــــــــاز

Name of Institution : *

اسم الجامعة

Start Date :

End Date :

Country : *

Name of Institution :

اسم الجامعة

Start Date :

End Date :

Country :

REGISTRATION

ترخيص مزاولة المهنة

Academic Degree : *

اسم المؤهل العلمي

Name of the Council : *

Address of the council :

Registration Date : *

Expiry Date :

Registration Number : *

رقم الترخيص

CURRENT & PREVIOUS EMPLOYMENT
خبرات العمل الحالية و السابقة

BEGIN FROM THE MOST RECENT

Employer Name : *

اسم المستشفى

Work Detail :

بإختصار

Designation : *

Duration : *

مدة العمل

Reason for leaving :

Last Drawn Salary :

Employer Name :

اسم المستشفى

Work Detail :

بإختصار

Designation :

Duration :

مدة العمل

Reason for leaving :

Last Drawn Salary :

Employer Name :

اسم المستشفى

Work Detail :

بإختصار

Designation :

Duration :

مدة العمل

Reason for leaving :

Last Drawn Salary :

Employer Name :

اسم المستشفى

Work Detail :

بإختصار

Designation :

Duration :

مدة العمل

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 :

المدة التي ستكون جاهز خلالها للسفر في حال تم قبولك

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

PERSONAL INFORMATION

Present Address :العنــــوان الحــــالــي

Permanent Address :العنـوان الـدائـــم

EMERGENCY INFORMATION

EDUCATION

PLEASE LIST THE HIGHESالT QUALIFICATION

المؤهلات العلمية من الاحدث للأقدم

OTHER TRAININGS

دورات أو تدريبات إضافية

INTERNSHIP

الامتيــــــــــــــــاز

REGISTRATION

ترخيص مزاولة المهنة

CURRENT & PREVIOUS EMPLOYMENTخبرات العمل الحالية و السابقة

BEGIN FROM THE MOST RECENT

RESIGNATION NOTICE

DOCUMENT CHECKLIST

BACKGROUND CHECK

If “yes”, please answer the following :

Present Address :
العنــــوان الحــــالــي

Permanent Address :
العنـوان الـدائـــم

CURRENT & PREVIOUS EMPLOYMENT
خبرات العمل الحالية و السابقة