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Registration Form

The document is an application form for registration with the Environmental Health Practitioners Council of Zimbabwe, requiring personal details, qualifications, and employment information from the applicant. It outlines the terms and conditions for an internship, including a one-year work requirement under supervision and subsequent application for a practicing certificate. The form also includes sections for official use regarding payment and registration approval.

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moyononsikelelo5
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204 views3 pages

Registration Form

The document is an application form for registration with the Environmental Health Practitioners Council of Zimbabwe, requiring personal details, qualifications, and employment information from the applicant. It outlines the terms and conditions for an internship, including a one-year work requirement under supervision and subsequent application for a practicing certificate. The form also includes sections for official use regarding payment and registration approval.

Uploaded by

moyononsikelelo5
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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ENVIRONMENTAL HEALTH PRACTITIONERS COUNCILOF ZIMBABWE

14 BUCKINGHAM ROAD P.O.BOX A1580


EASTLEA AVONDALE
HARARE HARARE

TELEPHONE NOs.: (263) (0242) 782260


(263) (0242)782262
FAX: (263) (0242) 782260

APPLICATION FOR REGISTRATION


(COMPLETE IN BLOCK LETTERS)

I hereby apply for registration as a………………………………………………………

PARTICULARS OF APPLICANT

TITLE: [ ] MR [ ] MRS [ ] MISS [ ] MS [ ] DR

[ ] MALE [ ] FEMALE

SURNAME……………………………………………………………………………….…………………..

FIRST NAMES ………………………………………………………………………….………………….

PREVIOUS SURNAME (where applicable)……………………………………………………………...


_____________________
DATE OF BIRTH ______________________

PLACE OF BIRTH TOWN………………………………………..COUNTRY……………………..

NATIONALITY ……………………ID NO.……………………………………………………………...

MARITAL STATUS: [ ] MARRIED [ ] SINGLE [ ] OTHER (STATE)…………….


CURRENT PHYSICAL ADDRESS……………………………………………………………………..

…………………………………………………………………E-Mail………………………………………

CELL NO: ………….……………………………………….WORK……………………………………..

PROFESSIONAL QUALIFICATIONS
QUALIFICATIONS NAME OF TRAINING DURATION AWARDED BY DATE
INSTITUTE FROM AWARDE
TO D

2/..

TICK AS APPROPRIATE
1. AREA OF EMPLOYMENT

[ ] GOVERNMENT [ ] MISSION [ ] LOCAL AUTHORITY

[ ] PRIVATE [ ] OTHER (Specify) ………………………………

2. EMPLOYMENT STATUS

[ ] FULL TIME [ ] PART TIME [ ] TEMPORARY

3. TYPE OF INSTITUTION

[ ] HOSPITAL [ ] CLINIC [ ] EDUCATION INSTITUTE

[ ] PHARMACY [ ] LABORATORY [ ] NURSING HOME

[ ] MINES [ ] MOBILE POST [ ] AGENCY

[ ] OTHER (Specify)…………………………

4. PROVINCE EMPLOYED

[ ] BULAWAYO [ ] HARARE [ ] MANICALAND

[ ] MASH CENTRAL [ ] MASH WEST [ ] MASH EAST

[ ] MASVINGO [ ] MAT. NORTH [ ] MAT.SOUTH

[ ] MIDLANDS

5. IF NOT EMPLOYED – REASON

[ ] POSITION NOT AVAILABLE [ ] FAMILY REASON

[ ] TO GO ABROAD [ ] UNDERTAKING FURTHER STUDIES

[ ] RETIRED [ ] OTHER (Specify)………………….

I hereby certify that the aforementioned information is correct.

DATE ………………………APPLICANT’S SIGNATURE……………………………


.

TERMS AND CONDITIONS FOR INTERNSHIP

a) You are required to work for a period of one year in any government health institution or any local authority under
the supervision of a Provincial Environmental Health Officer or Head of Environmental health Department.

.b) After completion of one year period, you are required to apply to Council for an open practicing certificate
enclosing a report from your supervisor. The report should state the level of your competence during the internship
period.

c) Your application for transfer from internship register to the main register shall be forwarded to the Practicing Control
Committee for consideration.

d) If the report is not satisfactory, you shall be afforded second chance of another one year.
e) In the event that the second report is not satisfactory, you will be brought before a special panel to decide on your
fate.

f) During the internship period, you are only required to work for the government or local authorities.

g) After the internship period, you are required to work in the country for three (3) years before obtaining Certificate of
Good Standing from the Council.

I have read, understood and agreed to the terms and conditions for Internship Registration above.

Signature_________________________________Date__________________________

FOR OFFICIAL USE ONLY

PAIS AMOUNT……………RECEIPT NO……………… DATE……………

APPROVED: [ ] YES [ ] NO

IF YES: DA TE OF REGISTRATION …………………REG. NO………………….

CONDITIONS: …………………………………………………………………………...

………………………………………………………………………………………………

IF NO: REASON ………………………………………………………………………...

DATE ……………………………………… SIGNATURE……………………………...

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