Appendix 10: Application form for Certificate of Good Standing
Form VII
Please affix firmly
a recent Passport -
size Color
photograph of
yourself here
HEALTH PROFESSIONS COUNCIL OF ZAMBIA
Plot 6640 Mberere Road, Olympia
P.O BOX 32554 Lusaka 10101, Zambia. Tel:+260 211 236241
Fax: +260 211 239317 Mobile 0770023624 +260 972666069
Email: info@[Link] Website:[Link]
APPLICATION FOR CERTIFICATE OF GOOD STANDING
(Certificate of Good Standing is valid for 6 months and applicable to all practitioners on full or specialist register)
PART 1 (FILLED BY APPLICANT)
Surname.…………………………………………………. Forename(s) …………………………………………
Profession.…………………………………………. Gender ………… Date of birth ……………….…………..
NRC/Passport No. ……………….……Nationality……………………. Tel/Mobile……………………………
Physical Address.………………………………………………… Postal Address ………………………………
Email address.………………………………………………………………………………………………………
Employer’s Address………………..………………………………………………………………………………..
I………………………………………………………………………………..do solemnly declare as follows:
a) That the information provided in this form is correct and true
b) That the attached documents are genuine
c) That I have never been debarred from Practicing my profession on the ground of professional misconduct;
d) That my name has never been removed from the register kept in accordance with the laws of any country in
which I have practised my profession; and
e) I make this solemn declaration conscientiously believing the same to be true to the best of my knowledge.
………………………………………
Signature of the Applicant
Declared at ………............. this ……………….. day of …………….. 20 …………….
Before me……………………………………………...……………………………………………………………
Commissioner of Oaths/Notary Public
Appendixes
a) Completed application form.
b) Recommendation by the head of institution or a supervisor in the same field, where the applicant last
practised, or recommendation by professional association where applicable (in Part B of the application
form).
c) Full or specialist registration with a valid annual practicing certificate. Practitioner must have worked for a
minimum period of one year.
d) Payment of the prescribed fee
e) Evidence that the practitioner is not under any investigation by the Council.
Notes
a) Practitioners with cases in progress or pending with the disciplinary committee of the Health Professions Council of Zambia a re not
entitled to receive a certificate of good standing.
b) Practitioners in annual fees arrears or with bad annual fees payment records will not be issued with a certificate of good standing.
c) Practitioners must be on full or specialist register.
d) Practitioners that need a certificate of good standing for gaining admission to a training institution or registration with o ther registration
bodies should furnish necessary supporting documents in completion wherewith, or names of persons in-charge and addresses of such
universities, training Institutions or registration bodies in lieu thereof.
PART B (To be completed by the head of the Institution or supervisor where the applicant is based,
or the Professional Association)
I Prof/Dr/Mr/Ms (Full Name) …………………………………………………………………….…………
(Indicate Full Names as they appear in the Register)
Profession ………………………………….……………HPCZ Registration. No …………..……………..
Position ……………………..…… at (Institution) ……………………..….…………………………….…
of P O Box……………………………………… Phone (Mobile)………..…………………………
Email……………………………………… Being a practitioner of good standing, I do hereby declare that I
have been and I am well acquainted with the said Prof/Dr/Mr/Ms ………………………………….………
HPCZ Reg. No.…………………………………… For the past …………years, and further declare that
during this time he/she: -
(i) Has been engaged in ……………………….……………………………………. practice.
(ii) Has conducted himself/herself well socially and in a responsible
manner.
(iii) His/Her character and conduct have been ………….…………………
……………………………………………………
Signature Official Stamp
PAYMENT METHODS
Zambia National Commercial Bank Using a Bill Muster form
Zambia National Commercial Bank Account no 1808893000143
Stanbic Bank, Arcades Branch Account No. 9130002152316 Sort code 040010
For Official use:
Amount Paid…………………………..Receipt No. ………………… …Signature …………… Date stamp……………
(Accounts Unit)
Received By (Name)……………………………………….….. Signature ………..…………….. Date………..…..…….
(Registry)
Reviewed By (Name)……………………………………...….. Signature …………….………… Date…..………..…….
(Registration Officer)
Verified By (Name)………………………………………….. Signature …………………….… Date ………………….…
(Senior Registration Officer)
Recommended By (Name)………………….……………….. Signature ……………………… Date ……………….…….
(Manager Registration)
Approved By (Name)……………………….……………….. Signature …………………….… Date… …………….….
(Registrar)