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[接上页] Occupational Therapists Board. (Enacted 1990) Cap 359B Sched 2 [regulations 7, 9, 14, 23 & 42] FORM 1 [regulation 7(1)] SUPPLEMENTARY MEDICAL PROFESSIONS ORDINANCE (Chapter 359) OCCUPATIONAL THERAPISTS (REGISTRATION AND DISCIPLINARY PROCEDURE) REGULATIONS Application for Registration/Provisional Registration as an Occupational Therapist I ..................................................................................................................................... (name in both English and Chinese) of......................................................................................................................................... (correspondence or home address) being qualified for registration under section 12(1)*(a)/(b)/(c)/section 15 of the Supplementary Medical Professions Ordinance apply for *registration/provisional registration as an occupational therapist and request that my name be placed on Part ............ of the Register. 2. I hold the following qualifications ...................................................................................... ............................................................................................................................................. ............................................................................................................................................. 3. I have the following professional experience ...................................................................... ............................................................................................................................................. ............................................................................................................................................. 4. My business address(es) *is/are as follows: (English) ............................................................................................................................... ............................................................................................................................................. (Chinese) .............................................................................................................................. ............................................................................................................................................. 5. My telephone numbers are: (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 .................................................. ﹜ .............................................................. the ............... day of ...................... 19 ..... (Signature of Applicant) Before me, ....................................................... .............................................................. (Name in block letters) (Signature) * Barrister/Commissioner for Oaths/Occupational therapist registered in Part I of the Register/Registered medical practitioner/Solicitor Photograph of Applicant + Please supply details of conviction. * Delete as inappropriate. (47 of 1997 s. 10) _____________ FORM 2A [regulation 9(1)] OCCUPATIONAL THERAPISTS BOARD HONG KONG SUPPLEMENTARY MEDICAL PROFESSIONS ORDINANCE (Chapter 359) Certificate of Registration Number on Register ................... This is to certify that ........................................................................................... whose address is .............................................................................................................................. ............................................................................................................................................. and whose photograph appears hereon was on the .......... day of ............. 19.......... admitted to Part .............. of the Register of Occupational Therapists. Dated this ........ day of ....... 19...... Photograph .................................................... Secretary, Occupational Therapists Board. (L.N. 87 of 2004) _____________ FORM 2B [regulation 9(2)] OCCUPATIONAL THERAPISTS BOARD HONG KONG SUPPLEMENTARY MEDICAL PROFESSIONS ORDINANCE (Chapter 359) Certificate of Provisional Registration Number on Register ................... This is to certify that ........................................................................................... whose address is .............................................................................................................................. ............................................................................................................................................. and whose photograph appears hereon was on the ........ day of ............. 19........ admitted to Part Ill of the Register of Occupational Therapists subject to the undermentioned conditions. |