Botswana Health Professions Council

Renewal form
For health professionals WISHING to have their registration renewed

You must complete all the sections of this form and attach all the appropriate documents and fees before sending the forms to BHPC offices. INCOMPLETE FORMS WILL NOT BE PROCESSED. The list of enclosures: 1. Certified evidence of change of name or surname [if applicable] 2. Original current annual license to practice [the blue card] NOTES If you have attained a new primary qualification* or a postgraduate specialist qualification in the last twelve months, please complete a registration application form. *Only qualifications for which professions are registrable according to Botswana Health Professions Act of 2001. Annual renewal fees shall be paid at the time of collecting the blue card for 2011/2012

RENEWAL OF REGISTRATION FOR YEAR 2011 2012

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Section 1
Category of professional registration for which renewal is applied

Identification details Name of the Applicant

(First Name) (Surname)

Botswana Health Professions Council Registration Number . Gender Male Female

Date of Birth (day/ Month/ year). Correspondence Address ... Email Mobile Telephone Fax . Immigration status Citizen Resident

Work Visa

Visitor Visa

Omang Number . (for citizens only) Passport Number Issued by Nationality of Passport .. Date of Expiry.

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Section 2
Qualification History Have you attained any additional qualification in the last 12 months which may not require separate registration [Tick below] Yes No

If Yes the complete the section Title of the qualification University Date Conferred . Country .

Enclosure of section 2 If you answered Yes please provide a certified copy of the qualification.

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Section 3
Employment History Part I Have you changed employment or position in Botswana in the last 12 months? Yes ___ No ___

If Yes, what is the position? .. Name of Employer/Institution . Tick appropriate employer from list provided: 1. Botswana Central Government Headquarters Referral Hospital District Hospital Primary Hospital.. 2. Local Government District health team Local Clinic 3. Mine Hospital. 4. Private Hospital 5. Private Clinic/Practice a. Are your principal or employed (please circle appropriately) 6. Private Pharmacy a. Are your principal or employed (please circle appropriately) 7. Other..please specify Address of the current Employer. Place/Location of Deployment: Health District Village /Town .. Phone of the employer fax Email

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Employment History Part II (for the purpose of updating the new electronic database) Please provide TYPED employment history during your professional career under the following headings. Start Date End Date Position Institution Country

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