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Get Hpcsa Form 26 Mtin

PROFESSIONAL BOARD FOR MEDICAL TECHNOLOGY APPLICATION FOR REGISTRATION AS AN INTERN MEDICAL TECHNOLOGIST Form 26 MTIN NB AN INCOMPLETE FORM WILL DELAY REGISTRATION Please PRINT and return the ORIGINAL FORM to The Registrar PO Box 205 Pretoria 0001 553 Vermeulen Street Arcadia Pretoria 0083 A. FOR OFFICE USE ONLY PERSONAL PARTICULARS Received on HPCSA Student Number MT-S. I Mr Mrs Miss Amount Surname Maiden name if applicable First names Receipt No. Identity No. Postal address No. Postal code Residential address Reg. Date Tel H W Cell Fax VERIFIED Email DATE Marital Status Race Divorced Asian Married African Coloured Single White Gender Male Female. PROFESSIONAL BOARD FOR MEDICAL TECHNOLOGY APPLICATION FOR REGISTRATION AS AN INTERN MEDICAL TECHNOLOGIST Form 26 MTIN NB AN INCOMPLETE FORM WILL DELAY REGISTRATION Please PRINT and return the ORIGINAL FORM to The Registrar PO Box 205 Pretoria 0001 553 Vermeulen Street Arcadia Pretoria 0083 A. FOR OFFICE USE ONLY PERSONAL PARTICULARS Received on HPCSA Student Number MT-S. I Mr Mrs Miss Amount Surname Maiden name if applicable First names Receipt No* Identity No* Postal address No* Postal code Residential address Reg* Date Tel H W Cell Fax VERIFIED Email DATE Marital Status Race Divorced Asian Married African Coloured Single White Gender Male Female. CAPTURED Country of origin Hereby apply to register as an Intern Medical Technologist and declare that I am the person mentioned in the attached documents and that these documents were granted to me and are my own lawful property. SIGNATURE Date B. The following is submitted in support of my application C. Current registration fee of R132. 00 until 31 March 2010. From 1 April 2010 it will be R152. 00. A letter from the supervising medical technologist registered in the relevant category t he/she is willing to act as supervisor for the intern for the duration of the internship accommodated for the full duration of the internship as well as the exact period of the internship TO BE COMPLETED BY THE UNIVERSITY IF DEGREE CERTIFICATE HAS NOT YET BEEN ISSUED Name of UnIversity It is hereby certified that complied with all the requirements for the qualification on of this institution day at a graduation ceremony on month year and that this qualification will be conferred/issued year. ORIGINAL OFFICIAL DATE STAMP OF INSTITUTION WE RECOMMEND him/her for registration SIGNATURE RECTOR/DEAN SIGNATURE REGISTRAR/PRINCIPAL Please complete for statistical purposes. NB Please note that the Council in the normal course of its duties reserves the right to divulge information in your personal file to other parties. FOR OFFICE USE ONLY PERSONAL PARTICULARS Received on HPCSA Student Number MT-S. I Mr Mrs Miss Amount Surname Maiden name if applicable First names Receipt No* Identity No* Postal address No* Postal code Residential address Reg* Date Tel H W Cell Fax VERIFIED Email DATE Marital Status Race Divorced Asian Married African Coloured Single White Gender Male Female. CAPTURED Country of origin Hereby apply to register as an Intern Medical Technologist and declare that I am the person mentioned in the attached documents and that these documents were granted to me and are my own lawful property.

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