LEAGUE OF FILIPINO HEALTHCARE PROFESSIONALS

United Arab Emirates

Membership Form

MEMBERSHIP APPLICATION/RENEWAL FORM

Date: (dd/mm/yyyy) _____ /______ / _______ MEMBERSHIP REQUIREMENTS:

APPLICATION FOR:  NEW MEMBER  MEMBERSHIP RENEWAL  Photo

 DOCTORS  FEE (AED 200)  Passport Copy

MEMBERSHIP
TYPE/FEES  OTHER ALLIED HEALTH
 Profile / CV
PROFESSIONALS  FEE (AED 100)

 PRC, MOH, or HAAD License

NOTE: Fees to be made in cash

APPLICANT DETAILS
Complete Name :

Company Name:

PASSPORT SIZE Company

PHOTO Address :

Telephone No.: Designation:

Fax no.: Mobile no.:

Email address:

FIELD OF PROFESSION / SPECIALITY :

IN WHAT WAY DO YOU WANT TO BE ACTIVE WITH LFHP-UAE?

LIST TWO LFHP-UAE MEMBERS TO ACT AS YOUR REFEREES AND SIGNATORIES:

1. 2.

Applicant signature: _________________________________ Date: (dd/mm/yyyy) _____ /______ / _______

THIS SECTION MUST BE FILLED IN BY THE LFHP-UAE EXECUTIVE DIRECTOR FOR MEMBERSHIP

Execom Review:  ACCEPTED  DECLINED AMOUNT RECEIVED:

Actual date of joining: (dd/mm/yyyy) _____ /______ / _______  200  100  Other ___________

________________________________
Approved by:
Executive Director for Membership Date: (dd/mm/yyyy) _____ /______ / _______

_________________________________
Approved by:
Chairman Date: (dd/mm/yyyy) _____ /______ / _______