APPLICATION FOR HEALTH PROFESSIONAL LICENSURE Passport Size

Photograph

Please complete this application on the computer then print and sign.
Hand-written applications will not be accepted.

Section 1: Application Details

Have you ever applied to No Yes

the Dubai Health Authority
(DHA) for licensure? Please give details

I am applying for: Physician or Dentist Allied Health

(please tick the appropriate
category) Nurse & Midwife Complementary Alternative Medicine (CAM)
I am applying for the For Official Use Only
professional license of: Approved Title :

Employing Facility _______________________________

Section 2: Personal Details (Please enter all details as per passport)

First name (given)

Middle name

Last name (family/surname)

Maiden name (if applicable)

DOB: (dd/mm/yyyy) Place of Birth

Passport Number Nationality

Date of Issue Date of Expiry

UAE National ID No Yes Number (if applicable)

Address in Home Country:

Address in UAE:
(if different from above)

Email Address: Tel. (business)

Tel. (local UAE
Tel. (residence)
contact no)

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Section 3: Education Information- 1

Name as per Certificate (If certificate name is different than name as per passport, then please
submit the relevant name change document)
University/Institution Name

College Name

University Address.

City Area

University Country Telephone No.

Qualification Attained
(e.g. Doctor of Medicine)
Major Subject Minor Subject

Student Identity / Roll No.

From To
Attendance Period
(dd/mm/yyyy) (dd/mm/yyyy)
Qualification Conferred Date (dd/mm/yyyy)

Education Information – 2 (When applicable)

Name as per Certificate (If certificate name is different than name as per passport, then please
submit the relevant name change document)
University/Institution Name

College Name

University Address.

City Area

University Country Telephone No.

Qualification Attained
(e.g. Doctor of Medicine)
Major Subject Minor Subject
Student Identity / Roll No.
From To
Attendance Period
(dd/mm/yyyy) (dd/mm/yyyy)
Qualification Conferred Date (dd/mm/yyyy)

Note: If you have more certificates, add them in a separate page.

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 Section 4: License Information

Name as per License

Issuing Authority Name

City Area

Issuing Authority Country Telephone No.

License Attained

License Type

License No.
From
Issue Period To (dd/mm/yyyy)
(dd/mm/yyyy)
License Conferred Date (dd/mm/yyyy)

Section 5: Experience Details

Please provide FULL details of employer for last 5 years starting in order from latest to the previous employer
First Employer Details
Name of the Employer
Address
Website address (URL)
Employment
Telephone No Code
From
Period of Employment (dd/mm/yyyy) To (dd/mm/yyyy)
Job Title / Designation Department
Full time / Part time (If part time please specify the agency name if any)
Second Employer Details

Name of the Employer

Address
Website address (URL)
Employment
Telephone No Code
From
Period of Employment (dd/mm/yyyy) To (dd/mm/yyyy)
Job Title / Designation Department
Full time / Part time (If part time please specify the agency name if any)

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Third Employer Details
Name of the Employer
Address
Website address (URL)
Employment
Telephone No Code
From
Period of Employment (dd/mm/yyyy) To (dd/mm/yyyy)
Job Title / Designation Department
Full time / Part time (If part time please specify the agency name if any)
Fourth Employer Details
Name of the Employer
Address
Website address (URL)
Employment
Telephone No Code
From
Period of Employment (dd/mm/yyyy) To (dd/mm/yyyy)
Job Title / Designation Department
Full time / Part time (If part time please specify the agency name if any)
Fifth Employer Details
Name of the Employer
Address
Website address (URL)
Employment
Telephone No Code
From
Period of Employment (dd/mm/yyyy) To (dd/mm/yyyy)
Job Title / Designation Department
Full time / Part time (If part time please specify the agency name if any)

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Section 6: Declaration

I here by attest that the following questions have been answered to the best of my knowledge:

1. Health status: Do you have any physical, mental or emotional condition which
may impair your ability to render professional services which are the subject of
this application? Yes No

2. License: Has your professional license in any country ever been suspended,
revoked or placed on a conditional status? Yes No

3. License: Are there any formal investigation pending against you at this time?
Yes No

4. Hospital Sanctions: Have you ever voluntarily surrendered or diminished your

clinical privileges pending an investigation that may have lead to censure,
restriction, suspension or revocation of such privileges? Yes No

5. Criminal Offences: Have you ever been convicted of a felony or involved in

charges relating to moral or ethical turpitude? Yes No

6. Disciplinary Actions: Have you ever been the subject of disciplinary

proceedings by any professional association or organisation Yes No

7. Malpractice Insurance Coverage: Has there ever been any malpractice claims
or lawsuits made against you alleging negligence or a treatment failure which
has been pending, open or closed during any of your health professional Yes No
practices?

If you answered yes to any of the above questions; please explain:

I hereby affirm by my signature, that the information I have completed under penalty of perjury is true and correct.
Should I furnish any false information in this application I hereby agree that such an act shall constitute cause for
the denial, or suspension or revocation of my license to practice?

Signature: ____________________________________

Date:29/04/2022

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 Letter of Authorization

I hereby authorize the Dubai Health Authority or DataFlow FZ LLC, its authorized affiliates, agents and
subsidiaries, acting on its behalf to verify information, documentation and back ground verification presented on
my application form including but not limiting to education, employment and licenses.

I hereby grant the authority for the bearer of this letter, with immediate effect, to release all necessary
information to the Dubai Health Authority or DataFlow FZ LLC, its authorized affiliates, agents and subsidiaries.

This information / documentation may contain but is not limited to grades, dates of attendance, grade point
average, degree / diploma certification, employment title, employment tenure, license attained, status of the
license, place of issue and any other information deemed necessary to conduct the verification of the
information / documentation provided.

I hereby release all persons or entities requesting or supplying such information from any liability arising from
such disclosure. I am willing that a photocopy of this authorization be accepted with the same authority as the
original. I further understand and acknowledge that this Information Release Form will remain valid for a period
of two years following its completion.
I confirm that all my certificates are affiliated and accredited from the issuing country
Personal Details:
(in BLOCK letters)

Full Name : _____________________________________________________________________

(Last/Surname) (First Name) (Middle Name)

Passport /Identity Card Number: _____________________________

_________________ ____________________
Signature Date (dd/mm/yyyy)

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Applicant Name:
Document / Information Checklist (To be filled by the applicant)
The following documents are mandatory. Please note that the request will not be processed if this information /
documents are not provided. (Please provide clear and legible copies)
A Applicable to all

1 Application form duly filled in its entirety

2 Valid Passport Copies

3 Degree certificate copies (copy of original certificate(s)& translated copy)

4 Experience letters from previous employers for the last five years

5 Medical / Nursing license copy (front and back)

6 Valid Good Standing Certificate or equivalent

7 Payment receipt copy

B Applicable in special circumstances

1 Copy of the surgical log book (for surgeons only)

2 Mark sheet for the final year (all year mark sheets for applicants who have studied in India)
Copy of the backside on the degree certificate ( for applicants having Afghanistan,
3 Egyptian & Pakistani degrees/certificates)

4 Certificate of Authenticity and Verification (CAV) for applicants who have studied in Philippines

5 Name change certificate, if applicable (Marriage certificate, affidavit, any legal document, etc.)

For Official Use Only

Decision:
 Approved As __________________________
 Pending As __________________________
Notes:
1. _______________________________________
2. _______________________________________
3. _______________________________________

 Rejected 4. _______________________________________

Credentialing:

_____________________ _________________ ____________________

Name Signature Date (dd/mm/yyyy)

Primary Source Verification (PSV): Basic Degree Professional license

Additional Degree Employment History
Applicant informed
_____________________ _________________ ____________________
Name Signature Date (dd/mm/yyyy)

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