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[接上页] PART Ia REGISTRATION NO. : ................................................................................................... NAME : .................................................................. ( ) ADDRESS : ................................................................................................... BUSINESS ADDRESS : ................................................................................................... QUALIFICATIONS AND DATE OBTAINED : ................................................................................................... ................................................................................................... DETAILS OF WORKING EXPERIENCE : ................................................................................................... ................................................................................................... CERTIFICATE OF REGISTRATION SERIAL NO. : ................................................................................................... DATE OF REGISTRATION : ................................................................................................... REMARKS : ................................................................................................... ................................................................................................... Photograph ............................................. Secretary, Physiotherapists Board. PART Ib REGISTRATION NO. : ................................................................................................... NAME : .................................................................. ( ) ADDRESS : ................................................................................................... BUSINESS ADDRESS : ................................................................................................... QUALIFICATIONS AND DATE OBTAINED : ................................................................................................... ................................................................................................... CERTIFICATE OF REGISTRATION SERIAL NO. : ................................................................................................... DATE OF REGISTRATION : ................................................................................................... REMARKS : ................................................................................................... ................................................................................................... Photograph ............................................. Secretary, Physiotherapists Board. PART II REGISTRATION NO. : ................................................................................................... NAME : .................................................................. ( ) ADDRESS : ................................................................................................... BUSINESS ADDRESS : ................................................................................................... QUALIFICATIONS AND DATE OBTAINED : ................................................................................................... ................................................................................................... DETAILS OF WORKING EXPERIENCE : ................................................................................................... ................................................................................................... CERTIFICATE OF PROVISIONAL REGISTRATION SERIAL NO. : ................................................................................................... DATE OF REGISTRATION : ................................................................................................... REMARKS : ................................................................................................... ................................................................................................... Photograph ............................................. Secretary, Physiotherapists Board. (Enacted 1996) Cap 359J Sched 2 FORMS [sections 7, 9, 14, 23 & 42] FORM 1 [section 7(1)] SUPPLEMENTARY MEDICAL PROFESSIONS ORDINANCE (Chapter 359) PHYSIOTHERAPISTS (REGISTRATION AND DISCIPLINARY PROCEDURE) REGULATION Application for Registration/Provisional Registration as a Physiotherapist I ............................................................................................................................... of (name in both English and Chinese).................................................................................................................................... being (correspondence or home address)qualified for registration as a physiotherapist under section 12(1)*(a)/(b)/(c)/section 15 of the Supplementary Medical Professions Ordinance apply for *registration/provisional registration as a physiotherapist and request that my name be placed on Part *Ia/Ib/II of the Register. |