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Name
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institution
Institution
Institution
Nationality:
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&
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Health Professions

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PERSONAL DETAILS

Address
Sex: Male [ ] Female [ ]
Omani [ ]

CURRENT EMPLOYMENT
Country

Country
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of
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Primary 6 years or Less

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Yes
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Directorate General of Administrative Affairs
Directorate of Registration and Licensing for

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Registration Category:………………….

Intermediate 6 years 12 years

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Post Basic Specialty:…………………….
Specialty (Specify) ……………………….

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[ ]
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Position held
GENERAL EDUCATION (Tick appropriate box)

NO
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[ ]
Qualifications
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QUALIFICATIONS
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POST-BASIC QUALIFICATIONS (Start with the most recent)

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BASIC ACADEMIC QUALIFICATIONS (Start with the most recent)

APPLICATION FOR REGISTRATION

Area of Practice
Duration
Duration
(Medical/ Nursing/ Pharmacy/ Allied Health)

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Marital Status: Single [ ] Married [ ]

University
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Government
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[ ]
PROFESSIONAL PRACTICE FOR THE FIVE YEARS (start with the most recent)
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From
D/M/Y
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Other [ ]

Secondary (12 Years)

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Private [ ]
Date completed
Date completed

To D/M/Y
Current Country:…………….. City:…………… PO Box:…………..Code:……………Tel:…………….....

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Passport Number …………………… MOH Staff Number ……............Email:………………………………

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Mr. / Mrs. / Ms: ……………………………………………………………………………………………………….

Other (Specify)……………… ID Card:……………… DOB:…………………

‫المديرية العامة للشئون اإلدارية‬
‫دائرة تسجيل وتراخيص المهن الصحية‬

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Directorate General of Administrative Affairs ‫المديرية العامة للشئون اإلدارية‬
Directorate of Registration and Licensing for ‫دائرة تسجيل وتراخيص المهن الصحية‬
Health Professions

Employer Address Date Commenced Grade Class

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CONTINUING EDUCATION FOR THE LAST 2 YEARS (Start with the most recent-not lees then 8 hrs.)
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Program (Topics covered) program (Topics covered) Month / Year
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CURRENT LICENSURE
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Type of License Country Registration No. Date of Issue Expiry Date
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Yes NO
Declaration Has never been removed or suspended from a register?
Has never been rejected from a register?
Has never been convicted in Oman or elsewhere of an
offense, related to professional practice?
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Medical Declaration Do you declare that you are such state of health and that no
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danger would be involved to a patient with whom you are
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likely to be contact? If the answer is no. Please explain why
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I, Declare that the information given in this application is correct and that I am the person referred
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to in this document. 1251

Applicant Signature ………………………………......... Date ………………….

Requirements: 1- Copy of Civilian Card. 2- Copy of Passport. 3-Copy of Contract/Contract.

Authorization
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This is to certify that applicant holds the qualification as required by the registration and licensing
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section.
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Authorized by:
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Name …………………………………….…………. Designation …………………………………….

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Signature …………………………………………… Date ……………………………………………...

Official Stamp
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