GAMLS “WOEZOR” REGISTRATION

A SPECIAL INITIATIVE BY VOLTA AND OTI BRANCHES Please attach your

Passport-size
photograph here;
GAMLS FORM A using paper clip.
Write your Name at
REGISTRATION No.: ……………….….. the back of the
picture.
Thank You!!!
AHPC PIN.: ………………………….…...

GHANA ASSOCIATION OF MEDICAL LABORATORY SCIENTISTS

APPLICATION FOR MEMBERSHIP REGISTRATION

PART 1: PERSONAL DETAILS

1. Name in full: _____________________________________________________________________________________________

Surname First Name Other Name(s)

Previous Name: __________________________________________________________________________________________

Surname First Name Other Name(s)

2. Gender: M / F Title: Mr Miss Mrs Dr Prof. Rev. Other

3. Date of Birth: / /___ Age: ______ Place of Birth:_______________________ Region: _____________________

4. Home Town: _________________________ District/Region: _____________________ Nationality: __________________

5. Marital Status: Single Married Divorced Widowed No. of Children: ________(if applicable)

CONTACT DETAILS

6. Work Address: ____________________________________________________________________________________________

_____________________________________________________________________________________________

7. Permanent Home Address: __________________________________________________________________________________

______________________________________________________________________________________
8. Current Employer’s Address: _______________________________________________________________
Staff ID Where applicable: _______________________ Current Grade: _____________________________

9. Telephone: _____________________________________________________________________________
Home Office Others
10. Mobile Cell Phone No (s): _________________________________________________________________
11. Email: _________________________________________________________________________________
12. EDUCATIONAL BACKGROUND AND QUALIFICATIONS: (Start from most current)
Name of School/Institution/University Date Qualification Year Obtained
From To

a)

b)

c)

d)

e)

f)

13. EMPLOYMENT HISTORY: WORKIN/PROFESSIONAL EXPERIENCE (Start with the most current)
Company/Organization/Institution/Firm Region Company Type Date Job Title Or
Public/Private From To Position

a)

b)

c)

d)

e)

f)
 14. Please indicate main specialty in which you practise with ‘1’

Clinical chemistry Cytology Haematology Microbiology

Histopathology Immunology Virology Parasitology

Genetics Transfusion science Academia Research

Other (please state) ____________________________________________________

15. Do you have a specific responsibility? (please tick one box only):
Training Research & Dev. Safety Management Quality Management Service

MEMBERSHIP STATUS
16. Have you applied for membership registration before? YES NO

17. Are you already registered by the Association? YES NO

If YES, state your Membership Registration Number: _________________ and the date of Issue of Certificate: _____/_____/______
If item (16) above is YES, but (17) is NO; then please, state the date (Month/Year) of the earlier application: /

18. How long have you practiced as a Medical Laboratory Scientist? [(<3); (3-5); (6-9); (10-15); (16-19); (≥20)] yrs.
19. Professional Involvement (Applicable ONLY for Upgrading of Membership status):
Briefly describe your contribution(s) to the GAMLS and/or the profession of Medical Laboratory science at the local, regional
and/or national level (e.g. Position(s) held, Publication(s), etc.): _____________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_____________________________________________________________________________________________ ____________
20. APPLICANT’S DECLARATION:
I wish to register with the Ghana Association of Medical Laboratory Scientists as a member, and I pledge to abide by the provisions
of its constitution. I declare that I have/have not (cross out as inappropriate) been convicted in Ghana or elsewhere of any offence
punishable with imprisonment since the date of this declaration made by me to the like effect for the purpose s of my application for
registration as a member of the GAMLS.
I solemnly declare that the information given in this application is correct to the best of my knowledge and belief.

Signature:…………………………………………… Dated; this ……….. day of …………………… 20…………………….

PART II: WITNESS/CONFIRMATION: (At least licentiate member in good standing OR Commissioner for Oaths)
The above person wishes to apply for GAMLS membership registration. I confirm that the information given in this application is
correct to the best of my knowledge and belief.

(Name in Block Letters)

Grade/Rank: ____________ Professional Membership: Licentiate Fellow
(Address): ____________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________

GAMLS Reg. No.: _______________________ AHPC Reg. (PIN) No.: ______________________

Contact No.(s): _____________________________________________________ Email: ______________________

Signature/Stamp: Date: ____________________________________
(Official Stamp-Commissioner for Oaths)
 PART III: FOR OFFICE USE ONLY
Date Application submitted:…………… Received By:…………………...............…… Sign/ Date:……………………………….
Application Vetted by (Regional Chairman): ……………………………………………………………………………………….
Remarks: Application for Registration Approved/Not Approved (Reason)
Registration No………………………………..… Regional Branch:……………………………………………………………..…
Certificate Issued: YES / NO Signature of Issuing Officer (Gen. Sec):……………… Date of Issue: / /

FOR FURTHER INFORMATION PLEASE CALL/ FAX: +233302680011 OR MOB: +233271029667

ACCOMPANIMENT/ OTHER REQUIREMENT:

NOTE: Please return the completed application form to the Regional Secretariat for onward submission to the
National Secretariat in Korle-Bu Accra.

You are required to INCLUDE (Tick the appropriate box for what is included)

 Two (2) recent Passport-size photographs

 Photocopy (ies) of Certificates obtained

 Photocopy of Current Payslip

 Student ID Card (Students only)

 National ID (Passport/Voter ID/NHIA etc

 AHPC Registration Certificate

 Current appointment letter (for Private sector staff)

Registration Fee:

Payable at the National secretariat upon submission of completed Application form as follows:

 GH¢20.00
NOTE:
 Additionally, you are required to pay a NON-REFUNDABLE Annual subscription fee of
2% of your basic pay.
 This form is for special registration and is valid for the period specified in the terms.

FOR FURTHER ASSISTANCE CONTACT 0244116678 / 0245785685 and

0200440005