Member Registration
Surname
First Name
Other Names
Gender(M/F)
Male
Female
Title(Dr.Prof.Rev)
--SELECT--
Dr.
Prof.
Rev.
Date of Birth
Place of Birth
Nationality
Marital Status(M/S)
Married
Single
Mobile 1
Mobile 2
Email
Division(Region Working)
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Upper West Region (UWR)
Upper East Region (UER)
Northern Region (NR)
Brong-Ahafo Region (BAR)
Ashanti Region (AR)
Eastern Region (ER)
Western Region (WR)
Central Region (CR)
Greater Accra Region (GAR)
Volta Region (VR)
Residential Address
Postal Address
Principal Office (Current place of work)
Professional Training
Insitution
Year(From-To)
Qualification
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Further Course & Seminars
Courses
Date & Duration
Place
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Working History
Hospital/Clinic
Address
Position
Date (From-To)
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GMA-Position & Appointment
Position/Appointment
National/Divisional
Date (From-To)
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Date Registered with Medical & Dental Council(M.D.C)
MDC Number
Applicant Signature
Date
Password
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