1. Pursuant to the Medical Act 1971, you are required to register with the Malaysian Medical Council (MMC) to practice medicine in Malaysia. Hence, your application should be submitted PRIOR to practice; 2. Pursuant to sections 12 and 13 of the Act, the Provisional Registration allows newly qualified practitioners to undertake the general clinical training needed for full registration under section 14 of the Act. 3. You are entitled for provisional registration if you: a. Possess a degree recognized by the MMC as listed in the Second Schedule or pass the Medical Qualifying Examination under section 12(1)(aa) of the Act; and b. Are appointed/employed by the public authorities. 4. A provisionally registered practitioner is only entitled to practice as a house officer in hospitals approved by the Medical Qualifying Board under section 13 of the Act. 5. T To o a ap pp pl ly y f fo or r P Pr ro ov vi is si io on na al l R Re eg gi is st tr ra at ti io on n, , the following documents should be submitted: : 5.1. Application form for Provisional Registration FORM 4; The application form should be completed i in n B Bl lo oc ck k C Ca ap pi it ta al l a as s p pr ri in nt te ed d i in n t th he e N NR RI IC C o or r P Pa as ss sp po or rt t preferably type-written. Please fill all mandatory fields marked * completely and legibly. *For resident and postal addresses, please provide addresses in Malaysia. 5.2. The Appendix A Form; 5.3. An original Deans Letter or certified true copy of a recognized basic medical degree. (For Indonesian graduates Certified true copies of both the Sarjana Kedokteran and Ijazah Kedokteran degrees.) 5.4. A copy of both the Compulsory Rotating Houseman/Internship Certificate and Bonafide Student Certificate (for Indian graduates only). 5.5. A copy of your result transcripts covering the WHOLE course/study duration and 5.6. Other documents will be detailed out in the CHECKLIST below.
Please take note: a. The following information is provided to assist you. b. Please read these notes for guidance before completing the Application Form. c. You are expected to observe and comply with ALL the terms and conditions stipulated herein. d. Not adhering to any of the requirements may result in undue and unnecessary delay in processing your application. e. The Malaysian Medical Council will NOT be held responsible for any delay due to your non-compliance with the terms and conditions set herewith. 6. Pursuant to section 19 of the Act, you are required to submit a copy of your recent medical report and sick leaves if you: 6.1. suffer from any medical illness or physical condition which may affect your professional duties; and 6.2. have any mental problem and/or have been admitted into a hospital for any mental problem. 7. ALL documents should be certified according to the Guideline for Document Verification; 8. If your printed names in any of the submitted documents differ, you are required to submit a Statutory Declaration; 9. If the original documents are not in either Bahasa Malaysia or English, you need to submit translated versions in either Bahasa Malaysia or English along with certified copies of the document in its original language. Translated documents are only acceptable if carried out by qualified translators or officers of appropriate embassy. 10. A twenty ringgit processing fee (pursuant to Regulation 25 of the Medical Regulations 1974) i in n b ba an nk k d dr ra af ft t, , m mo on ne ey y o or rd de er r, , p po os st ta al l o or rd de er r o or r c ch he eq qu ue e i in n f fa av vo or r o of f T Th he e R Re eg gi is st tr ra ar r o of f M Me ed di ic ca al l P Pr ra ac ct ti it ti io on ne er rs s w wi it th h y yo ou ur r n na am me e a an nd d i id de en nt ti it ty y c ca ar rd d n nu um mb be er r w wr ri it tt te en n b be eh hi in nd d t th he e p pa ay ym me en nt t s sl li ip p; ; 11. The application can be submitted in person or sent via post. 12. Y Yo ou u a ar re e a ad dv vi is se ed d t to o k ke ee ep p a a c co op py y o of f t th he e d do oc cu um me en nt ts s s su ub bm mi it tt te ed d f fo or r y yo ou ur r r re ef fe er re en nc ce e. 13. Please submit this application to: The Registrar of Medical Practitioners, Malaysian Medical Council, Block B, Ground Floor, J alan Cenderasari, 50590 KUALA LUMPUR 14. Before submitting, please refer to the CHECKLIST provided. 15. Upon receipt, you will be promptly notified in writing: a. If you are eligible to practice, you may report for duty and practice with immediate effect; or b. Of any shortcomings and to respond immediately. Your application will be processed and approved once the documents are complete. 16. Please allow us 4 (FOUR) weeks to process the Provisional Registration Certificate (Form 5). (NOTE The letter issued under paragraph 15(a) is sufficient for you to commence practice. You need NOT wait for the Certificate). 17. Your certificate will be send by post. If you want to collect it personally, please state it clearly in your application form. However, if you want someone to collect on your behalf, he needs to produce a Letter of Authorization during collection. 18. Please notify us about a change of address in writing by completing a new Appendix A Form. 19. Please feel free to contact us if you: a. were not promptly acknowledged after submitting your application;
b. do not hear from us after the processing period is over; and/or c. require any assistance or have any questions.
Your cooperation is greatly appreciated. Thank you. Yours sincerely,
Dr. Hj. Wan Mazlan bin Hj. Mohamed Woojdy, Secretary.
Dated : 14 September 2008.
Revised: First: 18 December 2008. Second: 11 June 2009. F FO OR RM M 4 4 ( (R Re eg gu ul la at ti io on n 2 20 0) ) M ME ED DI IC CA AL L A AC CT T 1 19 97 71 1 ( (S Se ec ct ti io on n 1 12 2) ) M ME ED DI IC CA AL L R RE EG GU UL LA AT TI IO ON NS S 1 19 97 74 4 A AP PP PL LI IC CA AT TI IO ON N F FO OR R P PR RO OV VI IS SI IO ON NA AL L R RE EG GI IS ST TR RA AT TI IO ON N
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8 8. . I I a at tt ta ac ch h: : ( (a a) ) d do oc cu um me en nt t i in n p pr ro oo of f o of f h ha av vi in ng g b be ee en n * *s se el le ec ct te ed d f fo or r ( (s su ub bj je ec ct t t to o m my y b be ei in ng g p pr ro ov vi is si io on na al ll ly y r re eg gi is st te er re ed d/ /e ex xe em mp pt te ed d f fr ro om m) ) e em mp pl lo oy ym me en nt t i in n a a r re es si id de en nt t m me ed di ic ca al l c ca ap pa ac ci it ty y u un nd de er r s se ec ct ti io on n 1 13 3 ( (2 2) ) o of f t th he e M Me ed di ic ca al l A Ac ct t; ; a an nd d
( (b b) ) d do oc cu um me en nt t o of f p pr ro oo of f o of f h ha av vi in ng g b be ee en n s se el le ec ct te ed d f fo or r s se er rv vi ic ce e i in n a a m me ed di ic ca al l c ca ap pa ac ci it ty y u un nd de er r s se ec ct ti io on n 1 13 3 ( (3 3) ) o of f t th he e M Me ed di ic ca al l A Ac ct t, , s su ub bj je ec ct t t to o m my y b be ei in ng g p pr ro ov vi is si io on na al ll ly y r re eg gi is st te er re ed d a an nd d h ha av vi in ng g s sa at ti is sf fi ie ed d t th he e p pr ro ov vi is si io on ns s o of f s se ec ct ti io on n 1 13 3 ( (2 2) ) o of f t th he e M Me ed di ic ca al l A Ac ct t. .
D Da at te e*: : / / / / . . . .. . S Si ig gn na at tu ur re e o of f a ap pp pl li ic ca an nt t*
* * D De el le et te e w wh hi ic ch he ev ve er r i is s i in na ap pp pl li ic ca ab bl le e. . D DE EC CL LA AR RA AT TI IO ON N
I I, , ( (f fu ul ll l n na am me e) )* . .. . . . t th he e a ab bo ov ve en na am me ed d a ap pp pl li ic ca an nt t, , h he er re eb by y d de ec cl la ar re e t th ha at t t th he e p pa ar rt ti ic cu ul la ar rs s s st ta at te ed d i in n t th hi is s a ap pp pl li ic ca at ti io on n a ar re e t tr ru ue e a an nd d c co or rr re ec ct t a an nd d t th he e d do oc cu um me en nt ts s a at tt ta ac ch he ed d a ar re e o or ri ig gi in na al l d do oc cu um me en nt ts s w wh hi ic ch h r re el la at te e t to o m me e. .
I I f fu ur rt th he er r d de ec cl la ar re e t th ha at t i im mm me ed di ia at te el ly y u up po on n b be ei in ng g p pr ro ov vi is si io on na al ll ly y r re eg gi is st te er re ed d, , I I s sh ha al ll l e en ng ga ag ge e i in n e em mp pl lo oy ym me en nt t i in n a a r re es si id de en nt t m me ed di ic ca al l c ca ap pa ac ci it ty y i in n a ac cc co or rd da an nc ce e w wi it th h t th he e p pr ro ov vi is si io on ns s o of f s se ec ct ti io on n 1 13 3 ( (2 2) ) o of f t th he e M Me ed di ic ca al l A Ac ct t * *a an nd d, , i im mm me ed di ia at te el ly y u up po on n c co om mp pl le et ti io on n o of f s su uc ch h e em mp pl lo oy ym me en nt t, , i in n s se er rv vi ic ce e i in n a a m me ed di ic ca al l c ca ap pa ac ci it ty y i in n t th he e p pu ub bl li ic c s se er rv vi ic ce e u un nd de er r s se ec ct ti io on n 1 13 3( (3 3) ) o of f t th he e M Me ed di ic ca al l A Ac ct t
I I h ha av ve e n no ot t a at t a an ny y t ti im me e b be ee en n f fo ou un nd d g gu ui il lt ty y o of f a an n o of ff fe en nc ce e i in nv vo ol lv vi in ng g f fr ra au ud d, , d di is sh ho on ne es st ty y o or r m mo or ra al l t tu ur rp pi it tu ud de e o or r a an n o of ff fe en nc ce e p pu un ni is sh ha ab bl le e w wi it th h i im mp pr ri is so on nm me en nt t ( (w wh he et th he er r i in n i it ts se el lf f o on nl ly y o or r i in n a ad dd di it ti io on n t to o o or r i in n l li ie eu u o of f a a f fi in ne e) ) f fo or r a a t te er rm m o of f t tw wo o y ye ea ar rs s o or r u up pw wa ar rd d. .
D Da at te e* / / / / . . . . . . . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . S Si ig gn na at tu ur re e o of f a ap pp pl li ic ca an nt t*
C CE ER RT TI IF FI IC CA AT TI IO ON N O OF F I ID DE EN NT TI IT TY Y I I, , ( (f fu ul ll l n na am me e) )* . .. .. . o of f ( (f fu ul ll l a ad dd dr re es ss s) )* . .. . b be ei in ng g ( (p pr ro of fe es ss si io on na al l s st ta at tu us s) )* . .. . d do o h he er re eb by y c ce er rt ti if fy y t th ha at t ( (n na am me e o of f a ap pp pl li ic ca an nt t) )* w wh ho os se e a ap pp pl li ic ca at ti io on n f fo or r r re eg gi is st tr ra at ti io on n a as s a a m me ed di ic ca al l p pr ra ac ct ti it ti io on ne er r i is s s su ub bm mi it tt te ed d a ab bo ov ve e i is s k kn no ow wn n t to o m me e p pe er rs so on na al ll ly y a an nd d i is s i in n f fa ac ct t t th he e p pe er rs so on n w wh ho os se e n na am me e a ap pp pe ea ar rs s o on n t th hi is s a ap pp pl li ic ca at ti io on n. .
D Da at te e* / / / / . .. . ( (S Si ig gn na at tu ur re e) )* F Fu ul ll ly y R Re eg gi is st te er re ed d M Me ed di ic ca al l P Pr ra ac ct ti it ti io on ne er r o or r A Ad dv vo oc ca at te e a an nd d S So ol li ic ci it to or r o or r a an n O Of ff fi ic ce er r i in n t th he e M Ma an na ag ge er ri ia al l a an nd d P Pr ro of fe es ss si io on na al l G Gr ro ou up p o of f t th he e P Pu ub bl li ic c S Se er rv vi ic ce e
A AP PP PE EN ND DI IX X A A F FO OR RM M
Please affix your recent passport size photo here (35mm x 45mm)
A AP PP PL LI IC CA AT TI IO ON N F FO OR R P PR RO OV VI IS SI IO ON NA AL L R RE EG GI IS ST TR RA AT TI IO ON N
1. NAME*: Dr. ... (I n Block Capital as Printed in the NRI C or Passport)
2. OTHER NAME: .... (I f any, including maiden name)
11. MODE OF CERTIFICATE DELIVERY: Please one only.
a. Please Post b. Collect In Person c. Somebody on my Behalf
S Si ig gn na at tu ur re e o of f a ap pp pl li ic ca an nt t: _____________ Date: ______/______/______
CHECKLIST: 1. The following documents need to be submitted by ALL applicants : 1.1. A completed Provisional Registration Application Form (Form 4) 1.2. A completed Appendix A Form 1.3. An original Deans Letter OR a certified true copy of basic medical degree (Please specify date of graduate if not indicated in any of the document). 1.4. A result transcripts covering the WHOLE course/study duration (Local public university graduates are exempted). 1.5. A recent passport-sized photograph. 1.6. A RM20 registration fees in bank draft/money order/postal order in favour of The Registrar of Medical Practitioners. 1.7. If the original documents are not in either Bahasa Malaysia or English: a. Translated documents b. Certified copies of the document in its original language. 1.8. Certified true copy of the medical report/sick leaves, if any. 1.9. Fitness to practice declaration form.
2. The following additional documents to be submitted by Malaysians only: 2.1. A certified true copy of an identity card. 2.2. A certified true copy of a birth certificate. 2.3. A certified true copy of a Sijil Pelajaran Malaysia or offer letter from SPA, whichever applicable.
3. The following additional documents to be submitted by Non-Citizens only: 3.1. A certified true copy of passport (Non-citizen). 3.2. A certified true copy of an offer letter from SPA. 3.3. A certified true copy of your marriage certificate for foreign spouse of Malaysian, if applicable.
4. The following additional documents to be submitted by Indian University Graduates only: 4.1. A certified true copy of a Student Bonafide Certificate. 4.2. A certified true copy of Rotating Internship Certificate.
5. The following additional documents to be submitted by Indonesian University Graduates only: 5.1. A certified true copy of Sijil Kedokteran (S.KED). 5.2. A certified true copy of Ijazah Kedokteran (Ijazah Profesi Dokter).
MALAYSIAN MEDICAL COUNCIL
GUIDELINE FOR DOCUMENT VERIFICATION
1. This Guideline for Document Verification is to ensure that documents presented by prospective practitioners are genuine and that the holder is the rightful owner. 2. A certified photocopy is considered valid and acceptable by the Malaysian Medical Council only if it bears the following criteria: 2.1. The document/s is signed by designated or authorized signatories as follows: a. Any public officials holding administrative and professional posts; b. Advocates and solicitors; c. Commissioner for Oaths; d. Notary Public; e. Embassy or Consulate officials holding administrative and professional posts; and f. Justice of Peace. *For Malaysian graduates from foreign medical universities that wish to apply for registration with the MMC, documentations should be certified by Malaysian government officers stationed in the respective foreign countries. 2.2. Every single page of the documents submitted should be certified. 2.3. Each certified documents shall bear ALL of the following details: a. The name of the person certifying in full; b. In case of a medical practitioner registered with the Malaysian Medical Council (MMC), the Full Registration number should be stated clearly; c. The designation of the person certifying in full; d. The complete address of the person certifying; e. These details must be rubber-stamped; and f. A signature and not an initial. 2.4. Documents certified by Commissioner for Oaths must bear a seal prescribed under Rule 19 of the Commissioner for Oaths Rules, 1993 enacted under the Courts of Judicature Act, 1964 Please take note: a. The following information is provided to assist you. b. Please read these notes for guidance before submitting your application. c. You are expected to observe and comply with ALL the terms and conditions stipulated herein. d. Not adhering to any of the requirements may result in undue and unnecessary delay in processing your application. e. The Malaysian Medical Council will NOT be held responsible for any delay due to your non-compliance with the terms and conditions set herewith. 3. An example of a proper and valid certification is as follows:
4. If your printed names in any of the documents submitted differ, please submit a Statutory Declaration.
5. If the original documents are not in either Bahasa Malaysia or English, you need to submit translated versions in either Bahasa Malaysia or English along with certified copies of the document in its original language. Translated documents are only acceptable if carried out by :
a. Malaysian certified court translators; b. Official Malaysian government agencies; c. Malaysian officers in the language faculty of public universities; d. Malaysian officers of the appropriate embassies
6. Any certification which does not conform to this Guideline will be considered invalid and NOT accepted.
7. Similarly, any document will be considered invalid and NOT accepted if: a. It is certified by an individual on behalf of another person without his own details printed; b. The signatures of the same individual are not similar or different.
8. For further details or enquiries, please contact us. Your cooperation is greatly appreciated. Thank you. Yours sincerely,
Dr. Hj. Wan Mazlan bin Hj. Mohamed Woojdy, Secretary.
Dated: 14 September 2008.
Certified True Copy,
Dr. Ahmad bin Muhammad, MMC Full Registration No. 27666 Family Health Physician, Klinik Kesihatan Putrajaya, 62250 PUTRAJAYA W.P. PUTRAJAYA. Signature of a Person Name in Full MMC Full Registration Number A Complete Address These details must be rubber-stamped.
Designation in Full Revised: First: 18 December 2008. Second: 11 June 2009. Third : 13 Okt 2011
THE MALAYSIAN MEDICAL COUNCIL
FITNESS TO PRACTISE DECLARATION FORM
FITNESS TO PRACTISE DECLARATION
The Malaysian Medical Council (Council) reserves all rights to withhold and/or to terminate an application for registration and/or to take any action it deems fit, if any information or documents tendered is found subsequently to be false.
I t is a criminal offence to make any false statements, to provide any false information and/or document(s) to the Council.
The Council may make any enquiries or obtain any information and documents that it deems appropriate.
I f you are unsure about whether a matter is important please inform the Council about it and provide full details to enable the Council to make a decision.
The information provided in this application will be governed by the Councils Guidelines on Confidentiality.
A. PERSONAL DETAILS
NAME :
I/C or PASSPORT NO :
FILE / MPM NO :
1. Health condition B. HEALTH
a. Do you have a health condition? (If the answer to the question is Yes please complete the rest of this section. If the answer is No, please go to section C.) Yes / No b. Please state the full nature of the condition (Please provide details in a separate sheet if necessary) c. What was the date of the diagnosis? d. Does the condition still affect you? Yes / No e. If no, please state the date when you were last affected by the condition
2. Current status of health condition
a. How does the condition affect you? (Please provide details in a separate sheet if necessary)
b. What was the date of the most recent episode or occurrence? c. Details of treatment and/or advice received following the most recent episode or occurrence. (Please provide details in a separate sheet if necessary) d. Details of all the doctors who have treated you (Name, Qualifications, Address, Telephone number and Email) (Please provide details in a separate sheet if necessary) e. Please state if your condition has resulted in any of the following: e. (i) Interruption or restriction of practice (Please provide details in a separate sheet if necessary) Yes / No e. (ii) Referral to occupational health and/or health assessments (Please provide details in a separate sheet if necessary) Yes / No
3. Employment
If you have been offered employment:
a. Have you informed your prospective employer of your condition? Yes / No
b. Contact details of (Name, Job title, Address, Telephone number and Email) of the person that we can confirm details, if necessary. (Please provide details in a separate sheet if necessary)
C. DISCIPLINARY RECORD
4a. Have you ever been reprimanded, suspended or deregistered by a medical regulatory authority in Malaysia or another country? (If the answer to the question is Yes please complete the rest of this Yes / NO
section. If the answer is No, please go to section D.) 4b. Details of the regulatory authority that imposed the sanction, including your reference/registration number; documentary evidence of the sanction imposed; and a full statement from you of the background and grounds of the sanction. Information of any appeal on the sanction (successful or not) must be submitted. (Please provide details in a separate sheet if necessary) 4c. Have you ever been refused registration or a licence to practise by any medical regulatory authority in Malaysia or another country? Yes / No 4d. Details of the regulatory authority who refused registration; documentary evidence of the grounds for refusal; and a full statement from you as to the background and grounds of the refusal. Information of any appeal on the refusal of registration (successful or not) must be submitted. (Please provide details in a separate sheet if necessary) 4e. Has an employer ever taken disciplinary action against you? Yes / No 4f. Documentary evidence of the nature of the disciplinary action undertaken by the employer; contact details (Names, Address, Telephone number and Email) of person(s) involved at the employing organisation that we can approach to secure further information and details; and a full statement on the nature of the allegation and any other information you would wish us to consider. Information of any appeal including legal action (successful or not) must be submitted. (Please provide details in a separate sheet if necessary) D. CRIMINAL RECORD
5a. Have you ever been convicted of an offence in a court of law or been Yes / No cautioned, either in Malaysia or another country? (If the answer to the question is Yes please complete the rest of this section. If the answer is No, please go to section E.)
5b. Details of the date of the conviction; name and address of the court; and the details of the penalty (if applicable) that was imposed. (Please provide details in a separate sheet if necessary)
E. DECLARATION
I declare that the particulars stated in this application are complete and the documents attached are true and authentic, and the information contained herein remains unchanged to date. To the best of my knowledge and belief, I have not withheld any material fact. I consent to the Malaysian Medical Council contacting the doctors I have listed in question 2d and/or the persons and/or the authorities I have listed in questions 3b, 4b, 4d and 4f should the Council decide to do so. Yes / No Signature Date
The draft of this document was prepared by the Evaluation Committee comprising Datuk Dr Noor Hisham Abdullah (Chairperson), Dr Milton Lum Siew Wah, Prof Dato Anuar Zaini Md Zain, Dato Dr Zaki Morad Mohd Zaher, Prof Datuk Abdul Razzak Mohd Said, Prof Dato Sri Abu Hassan Asaari Abdullah, Prof Lim Chin Theam, Prof Nor Azmi Kamarudin and Prof Dato Dr Abdul Hamid Abdul Kadir.
Adopted by the Council at its 312 th meeting on 15 January 2013