Application Form for the Assessment of Equivalency to U.S Emergency Medical Services

Click To Download American Health Guide

Section 1

Family Name Given Name (as per birth certificate or deed poll) Middle Name Gender Date Of Birth Nationality Permanent Address Post Code Current Address Phone Email Address

Section 2

1.RECOGNITION OF QUALIFICATIONS - Where is Current Certification Received From

Name of Competent Authority or Regulatory Body Address Post Code Website Email Your Professional Title Your Registration Number Other Name of Competent Authority or Regulatory Body Address Post Code Website Email Address Your Professional Title Your Registration Number

2. NAME AND ADDRESS OF EDUCATIONAL INSTITUTE WHERE YOU OBTAINED YOUR PROFESSIONAL QUALIFICATION

The qualification for the profession for which youare seeking registration. .

Name Post Code Title of Qualification

Date of Course

Commencement

Cessation

Duration of Course

Option 2 Name Post Code Title of Qualification

Date of Course

Commencement

Cessation

Duration of Course

3.PROFESSIONAL QUALIFICATIONS

If you have gained a further professional qualification relevant to your application please provide details below. If additional space is required, page 4 of this application form may be photocopied.

Name of Educational Institute Address Post Code Title Course

Date of Course

Commencement

Cessation

Duration of Course

Course Details Option 2 Name of Educational Institute Address Post Code Title Course

Date of Course

Commencement

Cessation

Duration of Course

Course Details

Section 3

Please provide details of all work experience since qualification. List in order commencing with your current position.

Current Position Name of Employer Address of Employer Post Code Contact Name

Durarion of Post

Date of

Commencement

Cessation

That position was subject to regulation by the following regulatory body (if appropriate).

Name of Regulatory Body Address Phone Email Website Regitration Number

Provide a full account of your role & responsibilities, typical work settings and details of how you are authorised to practice eg independently using guidelines or under medical practitioner license / instructions.

Previous Position

Current Position Name of Employer Address of Employer Post Code Contact Numnber

Durarion of Post

Date of

Commencement

Cessation

That position was subject to regulation by the following regulatory body (if appropriate).

Name of Regulatory Body Address Phone Email Website Registration number

Assessment of Qualification

I hereby declare and note that:

1. All the above information is true and accurate to the best of my knowledge and belief;

2. I hereby consent and give authority to AH to make any inquiry or inquiries with anybody or person in pursuance of my application for assessment of equivalence of professional qualification in pre-hospital emergency care.

3. Data Protection:By signing this form I consent to AH holding and processing my personal data for the purpose of assessing my professional qualifications. AH may also use the data I provide for communication purposes with me. I hereby give permission for American Health and its agents to share my results with Dubai Corporation for ambulance services and to use my analyzed data for research publicaly.