Healthcare Professions

Healthcare Division
Professions Division Application Number
TelNational Health
: +973 17 11 33Authority
Regulatory 33 (for official use only)
eMail
PO Box 11464: hcp@nhra.bh Test admission Number
Website
Manama : www.nhra.bh (if applicable)
P.O. Box
Tel: : 11464,
00973 1711 Manama, Kingdom of Bahrain
3333

Affix 1 x passport
photo here
APPLICATION FOR A LICENSE
TO PRACTICE AS
A HEALTH PROFESSIONAL

Please tick the relevant box:

DOCTOR NURSE ALLIED (continued)
 Practical Nurse  Medical Representative
 General  General Nurse  Nuclear Medicine Technologist
 Specialist  Specialist Nurse  Nutritionist
 Consultant  Midwife  Optometrist/Optician
 Pharmacist
DENTIST ALLIED  Pharmacy Technician
 Dental Hygienist  Physiotherapist
 General  Dental Technologist  Prosthetist/Orthotist
 Specialist  Dietician  Radiographer
 Consultant  ECG Technician  Radiologic Technologist
 Laboratory Technician  Respiratory Therapist
 Laboratory Technologist  Speech Therapist
1. PERSONAL DETAILS
Full name (as it appears in passport):

Previous name (if different from above):

Address:

Telephone Nos. (Mobile): (Business):

Fax No.: Email address:

CPR No.*: Passport No.:

Date of Birth: DD / MM / YYYY Country of Issue:

Gender (please tick):  Male  Female Language Proficiency:

Nationality:  Arabic  English  Other (please specify):

Prospective Employer/Sponsor:

Address:

Telephone Nos. (Mobile): (Business):

Fax No.: Email address:

* Can be provided upon arrival in Bahrain

Form 1: Application for license as a healthcare professional

2. PROFESSIONAL EDUCATION
Please list in chronological order (starting with most recent) your professional education (ie, education that is relevant to your application). Attach
additional sheets if necessary.Youwill also need to provide evidence of your qualification.
Name and address of University/Institution Program Year Year Qualification or
started completed Degree obtained

3. LICENSURE IN OTHER COUNTRIES

Please list ALL licenses which you hold or ever held in other countries. Attach additional sheets if necessary. You will also need to provide evidence of your
licensure history.
Country License Authority Type of License License Number Issue Expiration
date Date

4. WORK EXPERIENCE
Please list in chronological order (starting with most recent) work experience you have obtained following completion of professional education, including
internship training (where applicable). NOTE: Any absence from practise should be explained – leave no gaps from graduation to present. You will also
need to attach a CV.
Employer name and address Type: Area of experience/ Position Held From To
Government(G) Specialty
Private(P)
Other(O) MM / YY MM / YY

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5. IMPORTANT QUESTIONS Please answer “yes” or “no” to each of the following questions by ticking the relevant box:
YES NO
1. Has your registration/renewal certification/license to practise as a health professional ever
been refused in any country/state/jurisdiction?
2. Has your registration/license to practise as a health professional ever been cancelled/
suspended/removed for any reason in any country/state/jurisdiction?
3. Have you ever had disciplinary action taken against your registration certification/license
to practise as a health professional in any country/state/jurisdiction?
4. Have any conditions/restrictions ever been attached to your registration certification/
license to practise as a health professional in any country/state/jurisdiction?
5. Are there any special conditions/restrictions currently attached to your registration
certification/license to practise as a health professional in any country/state/jurisdiction?
6. Do you know of any investigation pending against a registration certification/license to
practise issued to you in any country/state/jurisdiction?
7. Have you ever been convicted of any criminal offence in any country/state/jurisdiction?

8. Are there any criminal investigations/charges pending against you in any country/state/
jurisdiction?
9. Do you have any health problem which in any way restricts your ability to practise as a
health professional?
*NOTE: If you have answered yes to any of the above questions, please attach a letter signed and dated by you,
describing the circumstances.*

6. DECLARATION Please tick each box to indicate that you have read each sentence in this Declaration.

 I, the undersigned, certify that I am the person referred to in this application for licensure in the Kingdom of Bahrain,
and that the statements herein are true to the best of my knowledge, information and belief.
 I further affirm that I am of good physical and mental health and of good moral character and I will keep the National
Health Regulatory Authority informed of any criminal charges and/or physical or mental conditions which jeopardize
the quality of care rendered by me to the public.
 I hereby authorize the National Health Regulatory Authority to request any information, files or records to be released
from relevant licensing authorities, educational facilities, and previous and past employers in connection with the
processing of this application.
 I have carefully read the questions in this application and have answered them completely, without reservations of
any kind and I declare under penalty of perjury that my answers and all statements made herein are true and correct.
 I understand that, should I furnish any false information in this application, such act shall constitute cause for denial,
suspension or revocation of my license to practise in the Kingdom of Bahrain and may result in criminal proceedings.

___________________________________________ ________________________
Signature Date

PLEASE DO NOT SUBMIT YOUR APPLICATION UNTIL YOU CAN ENCLOSE ALL REQUIRED DOCUMENTATION.
7. CHECKLIST Please use the checklist to make sure that you have attached all necessary documents.
 CPR/smart card*  General education certificate (secondary school)**
 Certified copy, front pages of passport  Original or certified copy, professional education certificate(s)
 1 passport-size photograph  Original or certified copy, full transcript of professional education
 Certified copy, statutory evidence of any  Certified copy, registration/license in other country/ies (if licensed
name change elsewhere)
 Health fitness certificate*  CV
 Prospective employer letter  Other: ________________________________________________
Please tick to confirm that Forms have been sent to the following with a request that they be sent directly to the NHRA:

 2 x References++ (FORM 2)  College/University++ (FORM 3)  All relevant Licensing Authorities (FORM 4)

* May be submitted on arrival in Bahrain ** Philippine trained nurses only ++ For health professionals who obtained their degree outside Bahrain
only

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