Herzzentrum Leipzig GmbH -Universitätsklinik-

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Registration form

Firstname *

Middlename

Lastname *

Current address for communication

Telephone

Mobile Phone Number

E-mail *

Date of birth (dd/mm/yyyy)

/ /

Gender

Male Female

Nationality

Medical registration no.

Total work experiance after post graduation (in years)

Current position

Educational qualification

Diploma/Degree	Name of Institution	Specialty	Year of passing

Professional experience (in chronological order starting with present employment for past 5 years)

Name and address of hospital	Period worked
Name and address of hospital	From	To

Please give reasons for any period of unemployment

Summary of clinical activity log (you are requested to list out the total number of procedures, or details of skills or procedures performed independently or assisted. Also mention any achievement in clinical activity / procedures.)

Papers published (if any)

Professional indemnity cover from hospital

Yes No

Any pending medico-legal issue(s) in a consumer court or any other court(s)?

Yes No

If yes, give details

If selected, how much time do you require to join

Time in weeks

Are you currently under any contract?

Contract

Yes No

If yes, contract valid till: (dd/mm/yyyy)

/ /

References

Referee's name	Organisation and address	Position held

Have you been or are you currently subject to any fitness to practice proceedings by an appropiate licensing or regulatory authority of any country?

Yes No

If yes, please provide details of the nature of proceedings undertaken, or contemplated, including the approximate date of proceedings, country where proceedings were undertaken and the name and address of the licensing or regulatory body concerned.

(*) required

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