AL-MOUWASAT MEDICAL SERVICES CO.
(MEDICAL - INTERVIEW REPORT)
NAME: NATIONALITY: DATE OF BIRTH:
POSITION APPLIED: SPECIALITY: GENDER: MALE FEMALE
EMAIL: MOB NO #: MARRIED SINGLE
DATE OF INTERVIEW: AGENCY NAME: ALSHAHEEN CO.,
IS THERE ANY HISTORY OF CHRONIC ILLNESS OR SUGERIES ? YES NO
IF THE ANSWER IS YES, MENTION THE TYPE OF ILLNESS OR THE NAME OF THE OPERATION:
I, SOLEMNLY AFFIRM THAT I HAVE NO HISTORY OF CHRONIC ILLNESS OR SURGERIES. (SIGNATURE)
QUALIFICATIONS
MBBS YES NO UNIVERSITY: YEAR PASSED:
MASTER DEGREE YES NO UNIVERSITY: SPECIALTY: YEAR PASSED:
PhD / FRCS / FRCP / FRCOG / MRCP / MRCOG UNIVERSITY: SPECIALTY: YEAR PASSED:
BOARD REGISTRATION YES NO VALIDITY OF BOARD REGISTRATION:
NAME OF THE BOARD REGISTRATION /MEDICAL COUNCIL:
PROMETRIC EXAM (SAUDI COUNCIL) PASSED YES NO EXAM SPECIALTY & DATE:
WORK EXPERIENCE
FROM TO
1. EMPLOYER NAME: POSITION: PERIOD
EXPERIENCE CERTIFICATE: AVAILABLE NOT AVAILABLE
FROM TO
2. EMPLOYER NAME: POSITION: PERIOD
EXPERIENCE CERTIFICATE: AVAILABLE NOT AVAILABLE
FROM TO
3. EMPLOYER NAME: POSITION: PERIOD
EXPERIENCE CERTIFICATE: AVAILABLE NOT AVAILABLE
SAUDI WORK EXPERIENCE, IF ANY YES NO
1. EMPLOYER NAME: FROM TO
PERIOD OF STAY
EXP. CERTIFICATE ATTESTED FROM CHAMBER OF COMMERCE YES NO
2. EMPLOYER NAME: FROM TO
PERIOD OF STAY
EXP. CERTIFICATE ATTESTED FROM CHAMBER OF COMMERCE YES NO
a) HAVE YOU EVER ACCREDITED/REGISTERED BY THE SAUDI COMMISSION BEFORE? YES NO
b) IF YES, PEASE WRITE YOUR ACCREDITATION NO. / REG. NO. : MOH LICENSE VALIDITY:
c) HAVE YOU EVER BEEN CONVICTED CONCERNING YOUR PROFESSIONAL PRACTICE YES NO
OR IS THERE ANY CURRENT TRAIL AGAINST YOU ?
d) CONTINUING MEDICAL EDUCATION (C.M.E. HOURS)
MOH LICENSE COPY AVAILABLE NOT AVAILABLE SCHS CERTIFICATE COPY: YES NO
OTHER GULF COUNTRY WORK EXPERIENCE, IF ANY YES NO
COUNTRY WORKED BEFORE:
1. EMPLOYER NAME: FROM TO
PERIOD OF STAY
EXP. CERTIFICATE ATTESTED SAUDI EMBASSY FROM COUNTRY OF ORIGIN YES NO
I do herby declare that above all informations are true to the best of my knowledge.
(Signature of the applicant)
MEDICAL INTERVIEW REPORT
FOR INTERVIEWER ONLY
CONFIDENTIAL
NAME OF THE APPLICANT:
POSITION APPLIED :
PERSONALITY: BEARING: APPEARANCE :
LANGUAGE FLUENCY: ATTITUDE:
PROFESSIONAL ABILITY:
YEARS OF EXPERIENCE : OTHER SKILLS, IF ANY:
QUALIFICATIONS MEETS JOB REQUIREMENT ? YES NO
EXPERIENCE MEETS JOB REQUIREMENT ? YES NO
SALARY EXPECTED: SALARY OFFERED:
COMMENTS:
SELECTED BACK UP REJECTED NAME OF INTERVIEWER & SIGN:
CONCUR: APPROVED:
(Department Head) (Chairman / Vice Chairman / C E O
