Online Institutions Registration Application for Registration of ServicesTick where Applicable* New Registration Change of Practitioner in Charge Change of Medical Director Change of Premises Addition of Ambulances Change of Level of care/training Accreditation of Training School Change 1. Full Name of Service*2. Proposed Level of Care / Training Offered*3. Physical Address* Street Address Address Line 2 City / Town Province / District 4. Postal Address* Street Address Address Line 2 City / Town Province / District 5. Phone Number*6. Email Address* 7. Board of DirectorsNames and Addresses(i) Name* First Last Address* Street Address Address Line 2 City / Town Province / District (ii) Name* First Last Address* Street Address Address Line 2 City / Town Province / District (iii) Name* First Last Address* Street Address Address Line 2 City / Town Province / District 8. Practitioner in ChargeName* First Last Address* Street Address Address Line 2 City / Town Province/ District Cell Number*Email* Qualification*Registration Number*Other Practices9. Medical DirectorName* First Last Address* Street Address Address Line 2 City / Town Province/ District Cell Number*Email* Qualification*Registration Number*10. PersonnelName* First Last Qualification*Reg. Number*Name* First Last Qualification*Reg. Number*Name* First Last Qualification*Reg. Number*Name* First Last Qualification*Reg. Number*Name* First Last Qualification*Reg. Number*Details of Owner of PremisesName* First Last Address* Street Address Address Line 2 City / Town I CERTIFY TO THE BEST OF MY KNOWLEDGE AND BELIEVE THAT THE FOREGOING PARTICULARS ARE TRUE AND REQUEST REGISTRATION OF THE AFOREMENTIONED SERVICEAttachments File uploadPlease upload any relevant Documents hereEmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.
