MEDICAL LABORATORY & CLINICAL SCIENTISTS COUNCIL

ZIMBABWE
71 Suffolk Road P O BOX A1620
Avondale West AVONDALE
HARARE HARARE

Telephone: 303348/334370 FAX 334730

APPLICATION FOR REGISTRATION

USE BLOCK CAPITALS

I hereby apply for registration as a …………………………………………………………………………...

1. PARTICULARS OF APPLICANT

TITLE: [ ] MR [ ] MRS [ ] MISS [ ] MS

[ ] DR [ ] MALE [ ] FEMALE

SURNAME …………………………………………………………………………………………………
FORENAMES ………….…………………………………………………………………………..……….
PREVIOUS SURNAME (where applicable) …………………………………………………………...
D D M M Y Y
DATE OF BIRTH

PLACE OF BIRTH: TOWN ………………………………….. COUNTRY ………………………….

NATIONALITY ………………………………………… ID No. ………………………………………..
MARITAL STATUS: [ ] MARRIED [ ] SINGLE [ ] OTHER (STATE) ………..………..
RESIDENTIAL ADDRESS ……….……………………………………………………………………….
……………………………………………...………………………………………………………………….
PHONE No. HOME ………………………WORK ……………………… CELL …..………..…………
E-MAIL ADDRESS ………………………………………………………………………………………..

QUALIFICATION (S) NAME OF TRAINING DURATION AWARDED DATE

INSTITUTE BY AWARDED
FROM TO

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I hereby certify that the aforementioned information is correct.

DATE …………………………………. SIGNATURE OF APPLICANT …………………………..

NOTE: (1) AN APPLICATION FEE OF US$6.00 WHICH IS NOT REFUNDABLE MUST

ACCOMPANY THIS APPLICATION FORM.

PLEASE ATTACH TWO CERTIFIED RECENT PASSPORT SIZE

PHOTOGRAPHS.

____________________________________

FOR OFFICIAL USE ONLY

RECEIVED (AMOUNT) ……….…………… RECEIPT No. ……….……… DATE ………………………

APPROVED: [ ] YES [ ] NO

IF YES: DATE OF REGISTRATION ……………………………… REG. No. ………………………….

CONDITIONS : …………………………………………………………………………………………………

IF NO: REASON ……………………………………………………………………………………………….

DATE …………………………………………………. SIGNATURE ………..………………………………

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71 Suffolk Road P O Box A1620
Avondale West Avondale
Harare Harare
Zimbabwe
Telephone: (263) (04) 303348
Fax: (263) (04) 334730

APPLICATION FOR PRACTISING CERTIFICATE

(Complete in block letters)

I hereby apply for a practicing certificate to practise as a ……………………………………………………………………………

………………………………………………………………………………………………………………...………. (state profession).

REGISTRATION NUMBER

SURNAME ……………………………………………………………………………………………………………………………….
FIRST NAMES …………………………………………………………………………………………………………………….……..
REGISTRATION ADDRESS/POSTAL ADDRESS…………………………………………………………………………….……
……………………………………………………………………………………………………………………………………………..
Please advise ANY CHANGE in your registered/registration particulars with authenticated documents where appropriate.

1. DETAILS OF LAST EMPLOYMENT

EMPLOYER …………………………………………………………………………………...…………………………
DATE OF EMPLOYMENT: FROM ………………………………..……. TO …………………..……………………

2. DETAILS OF INTENDED EMPLOYMENT IN ZIMBABWE

NAME OF PLACE OF PROPOSED EMPLOYMENT ……………………………………….…………………………

PHYSICAL ADDRESS …………………………………………………………………………..………………………
……………………………………………………………………………………………………………………...……...
POSTAL ADDRESS ……………………………………………………………………………………………………..
D D M M Y Y
COMMENCEMENT DATE

TICK AS APPROPRIATE
3. AREA OF EMPLOYMENT
[ ] GOVERNEMNT [ ] MISSION [ ] PRIVATE
[ ] LOCAL AUTHORITY [ ] OTHER (Specify) …………………………..………………………

4. EMPLOYMENT STATUS
[ ] FULL TIME [ ] PART TIME [ ] TEMPORARY

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 5. TYPE OF INSTITUTION
[ ] HOSPITAL [ ] CLINIC [ ] EDUCATION INSTITUTE
[ ] PHARMACY [ ] LABORATORY [ ] NURSING HOME
[ ] MINES [ ] MOBILE POST [ ] AGENCY
[ ] OTHER (SPECIFY) ……………………………………………………………………….

6. PROVINCE EMPLOYED

[ ] BULAWAYO [ ] HARARE [ ] MANICALAND

[ ] MASHONALALND CENTRAL [ ] MASHONALAND EAST

[ ] MASVINGO [ ] MATEBELELAND NORTH [ ] MIDLANDS

[ ] MATEBELELAND SOUTH [ ] MASHONALAND WEST

IT IS AN OFFENCE TO PRACTISE IF NOT IN POSSESSION OF A CURRENT PRACTISING CERTIFICATE.

NOTE: PERSONS WHO DO NOT REMAIN IN CONTINUOUS PRACTICE MAY BE

REQUIRED ON WISHING TO RESUME THEIR PRACTICE TO WORK IN A SPECIFIED
SITUATION FOR A SPECIFIC PERIOD.

Student Practising Certificate USD$12-00

DATE ……………………………………………. SIGNATURE …………………………………….………………

_________________________________

FOR OFFICIAL USE ONLY

APPROVED [ ] YES [ ] NO

CONDITIONS IF ANY …………………………………………………………………………………..………………………………

IF NO – REASON ………………………………………………………………….……………………………………………………
…………………………………………...…………………………………………………………………………..

DATE …………………………………………………… SIGNATURE ……..……………………………………………………….