Hpcsa Form 18 PDF Details

If you are a medical professional in South Africa, the chances are that at one point or another you will need to fill out and submit an HPCSA Form 18. This is a critical document for anyone who works as part of the health care industry, as it is used to register professional qualifications with the Health Professional Council of South Africa (HPCSA). It is not only important for practitioners to be correctly registered with this body but also necessary if they wish to practice legally within their profession. In this blog post we'll take a closer look at exactly what an HPCSA Form 18 entails and what it requires from those submitting it.

QuestionAnswer
Form NameHpcsa Form 18
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshpcsa login, hpcsa card download 2021, download hpcsa card, hpcsa practitioner card

Form Preview Example

Form 18

APPLICATION FOR RESTORATION OF NAME TO THE REGISTER IN TERMS OF SECTION 19(5) OF THE HEALTH PROFESSIONS ACT, 1974 (ACT No. 56 OF 1974)

NB: AN INCOMPLETE FORM WILL DELAY REGISTRATION

Please PRINT and return the FORM to:

The Registrar, PO Box 205, Pretoria 0001

553 Vermeulen Street, Arcadia, Pretoria 0083

A.PERSONAL PARTICULARS

HPCSA Registration Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I, (Dr, Mr, Mrs, Miss)

 

 

 

 

Surname:

 

 

 

 

 

 

 

Maiden name (if applicable):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First names:

 

 

 

 

 

 

 

 

 

Identity No.:

 

 

 

 

 

Postal address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Postal code:

 

 

Residential address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Postal code:

 

 

Tel (H):

 

 

 

 

 

 

 

 

 

 

(W):

 

 

 

 

 

Cell:

 

 

 

 

 

 

 

 

 

 

Fax:

 

 

 

 

 

Email:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* Marital Status:

 

Divorced

 

 

Married

 

Single

 

Gender:

 

Male

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* Race:

Asian

 

African

 

 

 

Coloured

 

White

 

Country of origin:

 

 

 

 

 

I request that my name be restored to the register of

 

 

 

for the Republic of South Africa

and hereby make oath and declare that I was registered as a

 

 

 

 

 

with the

registration number

 

 

 

 

 

My name was erased from the register under Section 19 of the Act.

I also delcare that I have never been convicted of any criminal offence or been debarred from practice by reason of unprofessional conduct in any country and that, to the best of my knowledge and belief, no proceedings involving or likely to involve a charge of offence or misconduct is pending against me in any country at present.**

SIGNATURE:DATE:

PRACTITIONER

FOR

OFFICE

USE ONLY

Received on

……………………………………..

Amount

……………………………………..

Receipt No.

……………………………………..

Date restored:

……………………………………..

CAPTURED

……………………………………..

DATE

…………………………………….

VERIFIED

……………………………………..

DATE

……………………………………..

Bank Details:

HPCSA

Bank:

ABSA

Branch:

Arcadia

Branch code:

334945

Acc. No.

0610000169

ORIGINAL OFFICIAL STAMP OF

COMMISSIONER OF OATHS

SIGNATURE

DATE

TO BE COMPLETED BY COMMISSIONER OF OATHS

**If you are unable to make the declaration in this paragraph, the Council requires full particulars of the reason for your inability to do so in order to consider the application.

B.

The following is submitted in support of my application:

Please fax your

 

 

1.

The amount of

in respect of my application for restoration.

application

 

 

form and proof

 

 

2.

A copy of my marriage certificate (should you wish to register in your married surname).

of payment to

 

 

(012) 328 5120

 

 

 

 

 

 

*Please complete for statistical purposes.

NB: Please note that the Council, in the normal course of its duties, reserves the right to divulge information in

your personal file to other parties.

GA/05-01-2011

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Part # 1 of completing hpcsa practitioner card

2. The third stage would be to fill in all of the following fields: Received on Amount Receipt No, SIGNATURE, PRACTITIONER, DATE, ORIGINAL OFFICIAL STAMP OF, COMMISSIONER OF OATHS, SIGNATURE, DATE, TO BE COMPLETED BY COMMISSIONER OF, If you are unable to make the, The following is submitted in, The amount of, in respect of my application for, A copy of my marriage certificate, and Please complete for statistical.

Writing segment 2 in hpcsa practitioner card

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