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Saudi Commission

For Health Specialties

Reg. No:

Date:

- 20
APPLICATION FORM
FOR PROFESSIONAL RE-REGISTRATION

Please affix
Recent Photo
here
.1

1. PERSONAL INFORMATION

First Name

Middle

Third

Family Name

Mobile No.

ID/Iqama/Passport NO.

Place of birth

" "
Date of Birth
Y

Country of current Residence

Blood Group

Postal Code

Gender

City

P.O.Box .

Nationality

E-mail address
.2

2.SPONSOR INFORMATION

Place of work
P.O.Box .

City

Postal Code

Tel No

Ex

Fax
. .3

3. Information Relevant to Your Professional Practice.

. ,

Has there been any change in your professional title?

If yes, please indicate and attach proof.

Current Title

Previous Title

Have you ever been accredited by the

commission before?

No

If Yes, please write your accreditation

Number
If it is No, please fill out the application form for accreditation
and professional registration :

Yes

: /

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.

List of CME Hours

Title of Activity

Recognition No.

Date

Certificate issued by

Total hours awarded

Important note: attach certificate of attendance of review.

CME
Hours

. :

.
. ,
All information stated above and certificate will be verified from their source inside/outside the kingdom.
Herewith I certify that all information provided in this application are correct to the best of my
knowledge and bear the responsibility for any incorrect or inappropriate information given.

Date /

Name /

Applicant Signature

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Re-Registration Requirements:

I.

A proof of coverage of required continuing

professional education hours (use attached list in
page 2).

II.

Identification letter by sponsor.

III.

Basic life support certificate.

IV.

Insurance against medical mistakes (GB).

V.

Registration fees are paid and receipt attached.

IMPORTANT NOTES:
Registration might be prematurely suspended
and/or revoked in the following conditions:
1) Proof of professional misconduct.
2) Violation of the ethics and codes of professional
practice.
3) Inability to practice because of contagious
disease, physical and/or mental handicap.
4) On the basis of a verdict / a medico legal
committee recommendation.
5) For common interest.

) ( 1
.) 2

.) 2

.) 3

.) ) ( 4
.) 5

:
/
:
.) 1
.) 2
/ ) 3
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. / ) 4
.) 5

The applicant once has been registered, is required

to inform the Council of any change in his/her post,
address or any information relevant to registration.
Failure to do so is considered as violation of this
application.

,
.

If the applicant wishes to renew his/her registration

for different description or a range of employment
for which he/she is not sponsored, he/she may be
required to pass a test of professional knowledge.

The duration of registration: Three years for nonSaudis and five years for the Saudis.

:
.

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