Physican Assistants Forms.pdf - Medical & Dental Council Ghana

MEDICAL AND DENTAL COUNCIL, GHANA
“Guiding the Profession, Protecting the Public”
PHYSICIAN ASSISTANTS
Application for PERMANENT Registration
MDCG FORM PA 2

Place Passport
picture using paper
clip.
Write your name at
the back of picture
1. Name in full:______________________________________________________________________
Surname First Name Other Names
2. Previous Name(s):_________________________________________________________________
Surname First Name Other Names
3. Sex: Male Female
4. Birth Date:_________________ Birthplace: _________________ Nationality:_________________
5. Mailing Address:___________________________________________________________________
_________________________________________________________________________________
City/Town
Region
6. Contact Numbers:__________________________________________________________________
7. Email Address:_____________________________________________________________________
8. Home/Permanent Address (if different from above)_______________________________________
_________________________________________________________________________________
City/Town
Region
9. Contact Numbers:__________________________________________________________________
10. Email Address:_____________________________________________________________________
11. School(s)/College(s) University Attended
i. ______________________________________ from_____/___/______ to ____/____/______
Institution D M Y D M Y
ii. ______________________________________
from_____/___/______ to ____/____/______
Institution D M Y D M Y
iii. ______________________________________
from_____/___/______ to ____/____/______
Institution D M Y D M Y
2

12. Qualification(s) for Registration
i. ___________________________________ ____/____/_____ _________________________
Degree/Diploma Date Granted Granting Institution
ii. ___________________________________
____/____/_____ _________________________
Degree/Diploma Date Granted Granting Institution
iii. ___________________________________
____/____/_____ _________________________
Degree/Diploma Date Granted Granting Institution
13. Have you ever been found guilty of any criminal offence Yes No
If Yes, provide details inclusive of date, court and offence:__________________________________
_________________________________________________________________________________
14. Referees: (Referees should be in practice for at least 8 years r and should be in Good Standing with
the Council)
i. Name_________________________________________________________________________
Address:_______________________________________________________________________
Tel. No:____________________ Fax________________ E-Mail:_________________________
ii. Name_________________________________________________________________________
Address:_______________________________________________________________________
Tel. No:____________________ Fax________________ E-Mail:_________________________
15. Certification Statement:
I _____________________________________________ declare that the information on this
application, other forms and documents submitted to the Medical and Dental Council of Ghana is
provided in good faith and is true, complete and accurate.
I understand that any misrepresentation may be cause for refusal or revoking of registration.
Signed______________________________
16. In pursuance of this application I enclose:
Date:____/______/_____
Day Mth. Year
Diploma(s) & Certificate(s) Certified Copy each (Originals should be available for inspection)
Passport Photograph
2 letters of Reference (Referees should be in practice for at least 8 years and should be in Good
Standing with the Council).
Registration Fees
3

17. Category:
I. Medical/Physician Assistant
II. Anaesthetist Assistant
III. Community Oral Health Officer
18. Work Experience:
Hospital
Discipline/Specialty
Start
Date
End
Duration
19. Other Experience:
Hospital
Discipline/Specialty
Start
Date
End
Duration
4

FOR OFFICE USE ONLY
Received By:__________________________________________________________
Checked By:__________________________________________________________
Date ____/____/_____
Day M Year
Date ____/____/_____
Day M Year
Amount Paid:_________________________________________________________ Receipt No.:__________
Signature of Officer:____________________________________________________
Date ____/____/_____
Day M Year
Registrar’s Comments:_______________________________________________________________________
__________________________________________________________________________________________
Signature:____________________________________________________________
Date ____/____/_____
Day M Year
Chairman’s Approval:________________________________________________________________________
__________________________________________________________________________________________
Signature:____________________________________________________________
Date ____/____/____
Day M Year
Approved: Yes No Date ____/____/____ Registration No.:_____________________
Day M Year
Entered Into Database By: _______________________________________________
Date ____/____/____
Day M Year
5