An Application Form for a License to Practice as a Health Cadre

For an application form, please fill in the form below:

An Application Form for a License to Practice as a Health Cadre

  1. Name:Gender: Male/female
  2. Date and place of birth:Nationality: Religion:
  3. Civil register/passport no.:Date: Issued by:
  4. Residence no.:Date: Expiry date:
  5. Name of the current insurer: Address:
  6. Permanent address in the home country:
  7. Endingdate of employment with the previous employer:
  8. Have you worked in Saudi Arabia before? Where?
  9. Have you obtained any licenses from MOH before? If yes, what are they?
  10. Specialty you seek to practice:

Pledge

I, the undersigned, pledge the following:

1-I shall not violate laws applicable in Saudi Arabia.

2-I shall work within the license given to me by the MOH.

3-I shall abide by the MOH regulations and laws regarding practice of the profession.

4-Aforementioned data is valid.

Health cadre’s name:

Signature:

Name of the private health institution owner:

Official seal:Signature:

Diagram 1: An Application Form for a License to Practice as a Health Cadre

A Health Cadre Registration Form

For a Health Cadre Registration Form, please fill in the form below:

A Health Cadre Registration Form

Nationality / Name
Place of birth / Date of birth
Religion / Blood type
Age / Gender
Profession specialty / Profession field
/ / 14 H / Date / Main qualification certificate
Certificate type
University nationality / University name
/ / 14 H / Date / Secondary qualification
certificate
Certificate type
University Nationality / University Name
Passport No. / / / 14 H / Entry date into Saudi Arabia
Place of Issue / Passport date

Owner’sname:Official seal:

Signature:

Diagram 2: AHealth Cadre Registration Form
Form Fields

Field / Description
Name / This field is used to write the name of the health cadre.
Place of birth / This field is used to write the place of birth of the health cadre.
Date of birth / This field is used to write the date of birth of the health cadre.
Nationality / This field is used to write the nationality of the health cadre.
Blood Type / This field is used to write the blood type of the health cadre.
Religion / This field is used to write the religion of the health cadre.
Gender / This field is used to write the gender of the health cadre.
Age / This field is used to write the age of the health cadre.
Profession field / This field is used to write the field of the health cadre’s profession.
Profession specialty / This field is used to write the specialty of the health cadre’s profession.
Main qualification certificate / This field is used to write the main qualification certificate of the health cadre.
Date / This field is used to write the date of the main qualification certificate of the health cadre.
Certificate type / This field is used to write the type of the main qualification certificate of the health cadre.
University name / This field is used to write the name of the university, from which the health cadre obtained the main qualification certificate.
University nationality / This field is used to write the nationality of the university, from which the health cadre obtained the main qualification certificate.
Secondaryqualification certificate / This field is used to write the secondary qualification certificate of the health cadre.
Date / This field is used to write the date of the secondary qualification certificate of the health cadre.
Certificate type / This field is used to write the type of the secondary qualification certificate of the health cadre.
University name / This field is used to write the name of the university, from which the health cadre obtained the secondary qualification certificate.
University nationality / This field is used to write the nationality of the university, from which the health cadre obtained the secondary qualification certificate.
Entry date into Saudi Arabia / This field is used to write the date when the health cadre entered Saudi Arabia.
Passport No. / This field is used to write the passport number of the health cadre.
Passport date / This field is used to write the date of issuing the passport for the health cadre.
Place of issue / This field is used to write the authority which issued the passport for the health cadre.

Table 2: Fields of the Health Cadre Registration Form