DECLARATION 1 Gu name RAP. Miele 2a sera Aram cnn BIN EASA A OLE abovenamed appt hereby deere that the partiuars stated in th appeaton ae tue and correctand the documents attached are onal documents which relate tome "Murher decae that immediatly pon belo posionai rested, shall engage employment ina esident medial capacity in acordance with the provistons of section 1 (2) ofthe Mess Act “and, immediately upon completion of such employment in Sevce ina medial capac in the public sence under section 1313] the Medical At. Thave nt at any tine ben found gui ef an efenceivching aud, dishonesty or moral urptude or an offence punshabie with imprsonment (whether in sel eny or nation too ip iw of = fine) for a term of two years or upward. Bi date: 22/2022 CERTIFICATION OF IDENTITY 1 (Gat name) De: inst... Mahomed. ot at sees) fei. egret, Koapdel Ride Lacapie aa tenon Lr a 24n, smn do Hereby certify that (name of applicant)... wi Badiuszamen, whose Seen ene eee personaly ands ia fat the person whose name appears on this applation pate:2O/.. 4.22% Folly Registered Medical Practitioner or ‘Advocate and Solicitor or an Officer in the Managerial and Professional Group of the Public Service en nairingMALAYSIAN MEDICAL COUNCIL FITNESS TO PRACTISE DECLARATION FORM {Pease not: MAT oy a ee oy The Malaysian Medic! Coun (the Council reserves all ahs to wihhold and/or to terminate an Besleton for repstraton andor to take ony action teens fi, any snlermaton or documents tensores fond subeequeny tbe fe, 5 ts cms tence to make ay fe ste, povieay fe fomaton ner ean) tte ©The Council may make any enquies or attain any formation and documents that deems SpFrOptE 4. you ate ensure atovt wheter a matric inpatant plese inform the Counc about tan prove fl deals to ‘enable the Counel to mae dessin 1 Thelnfecmatin provided inthis ppcaton willbe eovemes bythe Cones Guides on Confident | | BERSONAL DETAILS nena RADA MULCH RIER BADIU2T AMAA DIN eal Motnmer NRIC/Passport No. ee 8, HEALTH STATUS 1. Heath concition 3. Do you Rave a heath condition? ———Tves ie) (ithe answer tothe question s"Yes” please complete the rest of ths section Ifthe answers "No", please goto Section C) © Please state the full nature ofthe condition {Please provie detain separate sheet) What was the date ofthe diagnosis? ‘Does the condition still affect you? 657 No “elf no, please state the date when you were last affected by the condition. 2. Current status of health condition ‘2. How does the condition affect you? (Please provide details ina separate sheet) i What was the date of the most recent episode or occurrence? «Details of weatment and/or advice received following the most recent episode or occurrence. (Please provide details in a separate sheet) &.Details ofall the doctors who have treated you (Name, Qualifications, Address, Telephone number and Email) (Please provide details ina separate sheet) «Please state if your condition has resulted in any ofthe fllowing’ {interupion or restrtion of practice Yes/No | (Please provide detain a separate sheet) (W Referral to occupational health anor heath assessments Yes/No (Please provide details ina separate sheet) 3. Employment Hf you have been offered employment: ja {a Have you informed your prospective employer of your condition? ~_[ves7No |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 ina separate sheet). DISCIPLINARY RECORD ~~ {[43. Have you ever been reprimanded, suspended or deregistered by a medical Yes, oy regulatory authority in Malaysia or another countey? (ifthe answer to the question is "Yes" please complete the rest ofthis ection. f the answer is "No", please go to Section D), 4b, Details of the regulatory authority that imposed the sanction, including your Yes/No ‘eference/repistration number; documentary evidence of the sanction imposed: and full statement from you ofthe background and grounds of the sanction. Information of any appeal on the sanction (successful or not) must be submitted (Please provide detailsina separate sheet) ‘dc. Have you ever been refused registration or a license to practice by any medical | Yes/Ne | regulatory athortyn Malaysia or another eur? ‘4d. Details of the regulatory authority who refused registration; documentary evidence of | Yes/No | the grounds or ret andl atemert rom yu as tthe ecground nd trounds fhe lus. frmaton of ry apeaon the reul oexitaton (secs ont) muse submited ease prone etl ina seperate she!) 4e Harn employe ever aken asco seen east you? Ye7Ro| | @f- Documentary evidence af the nature of the di ry action undertaken bythe | Yes/No | employer; contact details (Names, Address, Telephone number and Email) of | persons inveved th employing orfantaton tht we can approach secre {ure normation nd deta and a statement onthe ature fhe lego80n and any ote formation you woud wish sto conser rarmation of ny pea Inuding ga action ces nt) mast be sued Please proce etl in a separate sheet . CRIMINAL RECORD a, Have you ever been canvicied ofan ofence n'a court of aw or been 3) cautioned, ether in Malaysia or anather country? (ifthe answer to the question is "Yes" please complete the rest ofthis section. Ifthe answer is "No", please goto Section E) | 5B. Details of the date ofthe conviction; name and address ofthe court and the details ofthe penalty (f applicable) that was imposed. (Please provide details ina separate sheet) £. DECLARATION | declare that he pris ated nti ppaton are complete andthe document atached ve true and authentic andthe infomation contained herein remains unchanged date To the best of my knowledge and belie, hve not withheld any material at T onsen tothe Malaysian Medical Counc conatng the dirs have ited in question 2a andfor te persons andor te autores have bed in questions 3, and at ‘should he Coyne psa do so. Sinsture Name: RATA NUKCHALET BADLULIANAN The daft of ts document wos prepared by the Evokcton Connie camering Datuk Dr Nor Hisham [Abdutoh(Choperson) Or Mito Lum Sew Wah, Prof Dolo" Anuer Zoi Md Zain, Coto Or Zaki Morad ‘ahd Zoher, Prof Datuk Abdul Razzok Mohd So, Prof Dot St Abu Hasson AS Abdul, Prof Lim Chin ‘eam, Prof Nor Rum Kamarudn and Prof Dot Or Abdul Homis Kb Rol Yes/No Date 20/ $ NOLL ‘Adopted by the Council at its 312°* meeting on 15 January 2017,