APPLICATION FOR HEALTH PROFESSIONAL LICENSURE Passport Size

Photograph

Please complete this application on the computer then print and sign. Hand-written applications will not be accepted.

Section 1: Application Details

Have you ever applied to the Dubai Health Authority (DHA) for licensure? I am applying for: (please tick the appropriate category) I am applying for the professional license of: Employing Facility
No Yes

Please give details

Physician or Dentist Nurse & Midwife

Allied Health Complementary Alternative Medicine (CAM)

Restotative Dentistry Specialist

For Official Use Only

Approved Title : _______________________________

Section 2: Personal Details (Please enter all details as per passport)

First name (given) Middle name Last name (family/surname) Maiden name (if applicable) DOB: (dd/mm/yyyy) Passport Number Date of Issue UAE National ID Address in Home Country: Address in UAE: (if different from above) Email Address: Tel. (residence)

Farshid

Mir Motalebi 26/11/1973 I17231163 01/03/2010

No Yes

Place of Birth Nationality Date of Expiry

Tehran Iranian 01/03/2015

Number (if applicable)

202,no 13, East third alley, ajodanieh st.,Shahid sabari st.,Movahed danesh st.,tehran, iran farshid_mm@yahoo.com 00982126126546 regulation@dha.gov.ae
Tel. (business) Tel. (local UAE contact no)

00989121902658 Page 1 of 7

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Section 3: Education Information- 1

Farshid Mir Motalebi

Name as per Certificate University/Institution Name College Name University Address. City University Country Qualification Attained (e.g. Doctor of Medicine) Major Subject Student Identity / Roll No. Attendance Period (If certificate name is different than name as per passport, then please submit the relevant name change document)

Shahid Beheshti University of Medical Sciences Faculty of Dentistry Daneshjo blvd., Evin square,.Shemiran Tehran Iran
Area Telephone No.

Doctor of Dentistry( general practitioner) Dentistry

From (dd/mm/yyyy) 01/10/1992 To (dd/mm/yyyy) Minor Subject

01/08/1998

Qualification Conferred Date (dd/mm/yyyy)

10/01/1999

Education Information 2 (When applicable)

Farshid Mir Motalebi

Name as per Certificate University/Institution Name College Name University Address. City University Country Qualification Attained (e.g. Doctor of Medicine) Major Subject Student Identity / Roll No. Attendance Period From (dd/mm/yyyy) (If certificate name is different than name as per passport, then please submit the relevant name change document)

Mashad university of medical sciences Faculty of Dentistry Opposite to Mellat park, Vakil Abad blvd. Mashad Iran specilialised dentist Restorative Dentistry 25/09/2001 06/09/2005
Minor Subject
To
(dd/mm/yyyy)

Area

O511

Telephone No. 8829501

25/09/2004

Qualification Conferred Date (dd/mm/yyyy)

Note: If you have more certificates, add them in a separate page.

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regulation@dha.gov.ae

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Section 4: License Information

Name as per License Issuing Authority Name City Issuing Authority Country License Attained License Type License No. Issue Period

Farshid Mir Motalebi Medical Council of the Islamic Repoblic of Iran Tehran Iran Dental Speciality clinic Private Clinic Establishment 711-70046-81
From
(dd/mm/yyyy)

Area Telephone No.

021 84130

12/01/2010 To (dd/mm/yyyy)

12/01/2012

License Conferred Date (dd/mm/yyyy)

Section 5: Experience Details

Please provide FULL details of employer for last 5 years starting in order from latest to the previous employer

First Employer Details Name of the Employer Address Website address (URL) Telephone No Period of Employment Job Title / Designation Full time / Part time Second Employer Details Name of the Employer Address Website address (URL) Telephone No Period of Employment Job Title / Designation Full time / Part time

self-employed, speciality dental clinic #302, 3rd floor, no. 446, shahid kolahdouz street, Tehran, Iran 009821 22617990
From
(dd/mm/yyyy)

Employment Code

up to now

To (dd/mm/yyyy) 10/01/2009 Restorative Dentistry specialist Department

(If part time please specify the agency name if any)

Shahid Montazeri speciality dental clinic West Sepand st., South Aban st., Karimkhan Zand blvd., Tehran, Iran 0098-21-88909388
From
(dd/mm/yyyy)

Employment Code

20/04/2011 restorative dentistry

To (dd/mm/yyyy) 10/01/2009 Restorative dentistry specialist Department

(If part time please specify the agency name if any)

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Page 3 of 7

Third Employer Details Name of the Employer Address Website address (URL) Telephone No Period of Employment Job Title / Designation Full time / Part time Fourth Employer Details Name of the Employer Address Website address (URL) Telephone No Period of Employment Job Title / Designation Full time / Part time Fifth Employer Details Name of the Employer Address Website address (URL) Telephone No Period of Employment Job Title / Designation Full time / Part time

private practice, dental speciality clinic #304, 3rd floor, Pastor building, pastor street, Bu-Ali sq., Hamedan, Iran 0098-811- 8352122
From
(dd/mm/yyyy) Employment Code

23/07/2008

22/07/2005

To (dd/mm/yyyy)
Department

Restorative Dentistry Specilist

From
(dd/mm/yyyy)

(If part time please specify the agency name if any)part -time

Employment Code

To (dd/mm/yyyy) Department

From
(dd/mm/yyyy)

(If part time please specify the agency name if any)

Employment Code

To (dd/mm/yyyy) Department

(If part time please specify the agency name if any)

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Letter of Authorization Section 6: Declaration

I hereby authorize following Health Authority or answered FZ LLC, of authorized affiliates, agents and I here by attest that thethe Dubaiquestions have been DataFlow to the best its my knowledge: subsidiaries, acting on its behalf to verify information, documentation and back ground verification presented on 1.my application form including but not limiting mental or emotional condition which Health status: Do you have any physical, to education, employment and licenses. may impair your ability to render professional services which are the subject of Yes No this application?

2. License: Has your professional license in any country ever been suspended,

I hereby grant the authority for the bearer of this letter, with immediate effect, to release all necessary informationor placed on a conditional status? Yes No revoked to the Dubai Health Authority or DataFlow FZ LLC, its authorized affiliates, agents and subsidiaries.

3.This informationthere any formal investigation pending against you to this time? License: Are / documentation may contain but is not limited at grades, dates of attendance, grade point
Yes No average, degree / diploma certification, employment title, employment tenure, license attained, status of the clinical privileges pending an investigation that may have lead to censure, information / documentation provided. restriction, suspension or revocation of such privileges? Yes No

4.license, place of issueHave you ever voluntarily surrendered or necessary to conduct the verification of the Hospital Sanctions: and any other information deemed diminished your

5.I hereby release all persons youentities requesting or of a felony or involved in Criminal Offences: Have or ever been convicted supplying such information from any liability arising from
Yes No charges relating to moral or ethical turpitude? such disclosure. I am willing that a photocopy of this authorization be accepted with the same authority as the of proceedings by any its completion. two years following professional association or organisation Yes No

6.original. I further understand and acknowledge that this Information Release Form will remain valid for a period Disciplinary Actions: Have you ever been the subject of disciplinary 7.I confirm that all my certificates are affiliated and ever been any malpractice claims Malpractice Insurance Coverage: Has there accredited from the issuing country
or lawsuits made Personal Details: against you alleging negligence or a treatment failure which has been pending, open or closed during any of your health professional (inpractices? BLOCK letters) Yes No

Full Name : _____________________________________________________________________ If you answered yes to any of the above questions; please explain: (Last/Surname) (First Name) (Middle Name)

Passport /Identity Card Number: _____________________________

I hereby affirm by my signature, that the information I have completed under penalty of perjury is true and correct. Should I furnish any false information in this application I hereby agree that such an act shall constitute cause for the denial, or suspension or revocation of my license to practice? _________________ Signature: ____________________________________ Signature Date:20/03/2011 ____________________ Date (dd/mm/yyyy)

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Applicant Name: Document / Information Checklist (To be filled by the applicant)

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Page 6 of 7

T he following documents are mandatory. Please note that the request will not be processed if this information /

A
1 2 3 4 5 6 7

Applicable to all
Application form duly filled in its entirety Valid Passport Copies Degree certificate copies (copy of original certificate(s)& translated copy) Experience letters from previous employers for the last five years Medical / Nursing license copy (front and back) Valid Good Standing Certificate or equivalent Payment receipt copy

B
1 2 3 4 5

Applicable in special circumstances

Copy of the surgical log book (for surgeons only) Mark sheet for the final year (all year mark sheets for applicants who have studied in India) Copy of the backside on the degree certificate ( for applicants having Afghanistan, Egyptian & Pakistani degrees/certificates) Certificate of Authenticity and Verification (CAV) for applicants who have studied in Philippines Name change certificate, if applicable (Marriage certificate, affidavit, any legal document, etc.)

For Official Use Only Decision:

Approved As __________________________ Notes: 1. _______________________________________ 2. _______________________________________ 3. _______________________________________ 4. _______________________________________

Pending As __________________________
Rejected

Credentialing: _____________________ Name Primary Source Verification (PSV): Applicant informed _____________________ Name _________________ Signature ____________________ Date (dd/mm/yyyy) _________________ Signature Basic Degree Additional Degree ____________________ Date (dd/mm/yyyy) Professional license Employment History

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