SUPPLEMENTARY MEDICAL PROFESSIONS ORDINANCE

(Chapter 359)
PHYSIOTHERAPISTS (REGISTRATIONAND DISCIPLINARY
PROCEDURE) REGULATION
Application for Registration
as a Physiotherapist

Wan, Shun Chit Walter 尹淳哲

I …………………………………………………………………………………of
(name in both English and Chinese)

………………………………………………………………………………………………….…..
House 23, 10th Street, Hong Lok Yuen, Tai Po, New Territories, Hong Kong
(correspondence or home address in both English and Chinese)

第⼗街⼆⼗三號，康樂園，⼤埔，新界，香港
……………………………………………………………………………………………….being
qualified for registration as a physiotherapist under section 12(1)*(a)/(b)/(c) of the
Supplementary Medical Professions Ordinance apply for registration as a physiotherapist and
request that my name be placed on Part *Ia/Ib of the Register.

2. I hold the following qualifications (please state qualifications obtained in

chronological order):
Qualification Issuing Authority Date Issued
Physiotherapy BSc (Hons) King’s College London 15/07/2022

3. I have the following professional experience (please state professional experience

obtained in chronological order:
Period
Post Title Name of Organization/company
From To

2
4. My business address(es) *is/are as follows:
(English) …………………………………………………………………………………………
……………………………………………………………………………………………………
(Chinese) ………………………………………………………………………………………..…
……………………………………………………………………………………………………

5. My telephone numbers are …………………

95451885 (Home) ………………….(Office).

6. I *†have/have not been convicted in Hong Kong or elsewhere of an offence

punishable with imprisonment. I *have/have not been found guilty in Hong Kong or elsewhere
of unprofessional conduct. I *am/am not the subject of an existing order under section 22(1)(i)
or (ii) of the Supplementary Medical Professions Ordinance.

I declare that the information given in this application is correct to the best of my
knowledge and belief.

Signed at ………………………………………..
………………………………………………….. ……………………………………………….
(Signature of Applicant)
the …………day of …………………. 20……...

Before me,

…………………………………………… ………………..………………………………
(Name in block letters) (Signature)

* Commissioner for Oaths /

* Solicitor / Barrister / Part Ia Physiotherapist /
* Registered Medical Practitioner.

Photograph
of
Applicant

† Please supply details of conviction.

* Delete if inappropriate.