MEDICAL PRACTITIONERS AND DENTISTS ACT, 1987
No 17 OF 1987
MEDICAL PRACTITIONERS AND DENTISTS (REGISTRATION AND MISCELLANEOUS FEES)
REGULATIONS, 1988
APPLICATION FOR REGISTRATON
To: THE REGISTRAR, MEDICAL COUNCIL OF MALAWI, P.O. BOX 30787, CAPITAL CITY, LILONGWE 3
Email:medcom@[Link], E-Diary :[Link]
1. Full names of the applicant: Dr./Mr./Mrs./Miss ____________________________________________________
_______________________________________________________________________________________________
2. Date of Birth ___________________________________________________________________________________
3. Marital status: single [ ], married [ ], widowed [ ], divorced [ ], other [ ] ______________________
Gender: Male [ ], Female [ ] Previous MCM registration number _______________________________
4. Address of the applicant ________________________________________________________________________
_______________________________________________________________________________________________
Telephone No.___________________Cell No. ._______________________Email ________________________
5. Nationality of applicant: Malawian, Yes [ ], No [ ] If no, please specify the country of origin, and attach the
following documents; certified copy of professional certificates, evidence of current registration, Curriculum Vitae,
Certificate of goodstanding, two passport sized photos
_______________________________________________________________________________________________
6. Profession in respect of which the application for registration is made _______________________________
_______________________________________________________________________________________________
7. Application for registration on the register of _____________________________________________________
_______________________________________________________________________________________________
I the above-named applicant hereby apply for registration on the afore-mentioned register and submit herewith-
*(a) the prescribed application fee of K____________________________________________________________
*(b) the prescribed registration fee of K___________________________________________________________
*(c) the following documents in support of my application, certificate [browse], diploma [browse]
Degree [browse], masters [browse], PhD [browse], COGS [browse]
Curriculum Vitae [browse], evidence of current registration certiticate [browse]
Two passport sized photos [browse]
Date __________________________________ ____________________________________
Signature of applicant
[*Note 1. Fee must be payable by cash or direct deposit made in favour of the Medical Council of
Malawi. Account Name, Medical Council of Malawi, National Bank, Capital City Branch, Current
Account number 1040669, swift code NBMAMWMW007.
2. Application fee is not refundable. Registration fee shall be refundable if application for registration has not been accepted .
Registration has not been accepted.]
MEDICAL PRACTITIONERS AND DENTIST ACT, 1987
No 17 OF 1987
MEDICAL PRACTITIONERS AND DENTISTS (REGISTRATION AND MISCELLANEOUS FEES)
REGULATIONS, 1988
STATUTORY DECLARATION
I, ………………………………………………………………………………….. do solemnly and declare as follows:
1. That I am the holder of the following degrees, diplomas or certificates granted to me after examination
by a university, college, medical or dental school, or other examining authority , and that the courses of study
in the professional subjects with respect to which the degrees, diplomas or certificates which I hold were granted
covered the following periods-----
University, College, medical Period Degree,
or dental school or other Diploma or Examining
institution Certificate Authority
From To
1.……………………………………………………………………………………………………………………………………..
2……………………………………………………………………………………………………………………………………...
3……………………………………………………………………………………………………………………………………...
4……………………………………………………………………………………………………………………………...............
2. That I have completed the following additional courses of training and had the following experience
in the practice of my profession, namely------
Period
Description of Training or Experience From To
………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………….
3. That I would, so far as professional qualifications are concerned, be entitled to practice my profession
in the country, state or territory in which my professional qualifications were granted.
4. That -----
(a) I have never been debarred from practicing my profession on the grounds of professional misconduct;
(b) my name has never been removed from any register or members of my profession kept in accordance
with the laws of any country or state in which I have practiced my profession; and
(c) no inquiry is pending which may result in an action being taken which is referred to in subparagraph
(a ) Or (b).
And I make this solemn declaration conscient
iously believing the same to be true …………………………………….
Signature
DECLARED at …............................................................ this …....................................... day of ……………………. 20………
Before me …..........................................................
Signature of Attesting Authority
…………………………………………………
Capacity of Attesting Authority (e.g. Notary
Public, Commissioner for Oaths, etc.)
NOTE: This declaration, if made
(a) in Malawi , must be made under the Oaths, Affirmations and Declarations Act (Cap. 4:07);
(b) in any other Country under any law for the time being in force to take or receive an oath,
an affirmation or a declaration;
(c) in any other place, must be made before a British Council or vice-consul or before any person having
authority under any Act of Parliament of the United Kingdom for the time being in force to take or
receive an oath, an affirmation or a declaration.
FOR OFFICIAL USE ONLY
DOCUMENT CHECKLIST (Tick where applicable)
REQUIRED DOCUMENT DATE SUBMITTED RECEIVED BY COMMENT
Application in writing
Application Form
Notorised Statutory Declaration form
Copy of academic qualifications
Copy of professional qualifications
Copy of National ID
Copy of current registration certificate
Certificate of Good Standing
CV
Two passport size photographs
Relevant payment
(GR#)
Received by: ……………………………………… Checked by:…………………………………………….
Receptionist Registry Clerk
Verified by:……………………………………...
Registration Officer
ASSESSMENT REPORTS CHECKLIST (Tick where applicable) NAME OF HOSPITAL:
DEPARTMENT DATE RECEIVED BY COMMENTS
SUBMITTED (INITIAL)
COVER LETTER/REFERENCE
Male & Female medical wards
OPD (Adult)
OPD ( Ufive)
Casualty & Orthopedics
Health Centre Management
Children’s/ Paediatrics
Obstetrics & Gynaecology
Surgery
Medicine
Paediatrics
Dental
Eye/ Opthalmology
Muscoloskeletal
Burns
Cardiorespiratory
Neurology
Orthopaedics
Oncology
Other (specify)
Note: Practitioners who have repeated a rotation should submit both initial and remedial assessment forms
Received by:……………………………… Checked by:……………………………………
Registry Clerk Registration Officer