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PROFESSIONAL BOARD FOR OPTOMETRY AND DISPENSING OPTICIANS APPLICATION FOR RECOGNITION OF DIAGNOSTIC PRIVILEGES Form 19 ODO NON COMPLIANT APPLICATION WILL BE REJECTED AND SENT BACK TO YOU Please PRINT and return the ORIGINAL FORM to The Registrar PO Box 205 Pretoria 0001 by registered mail for ease of tracking mail 553 Madiba Street Arcadia Pretoria 0083 A. FOR OFFICE USE ONLY PERSONAL PARTICULARS Received on. HPCSA Registration Number Amount I Dr Mr Mrs Miss Surname Receipt No* Maiden name if applicable First names No* Identity No* Postal address Reg* Date Postal code Residential address Tel H W Cell Fax Email Marital Status Race Asian Divorced African Married Coloured Gender Single White Male Female Country of origin I certify that the application meets the requirements as outlined in section B and that I have verified the Registration Officer hereby apply for recognition of Diagnostc privileges in Optometry and declare that I have complied with Signature I declare that I am the person referred to in the certificate below. I also declare that I have never been convicted of any criminal offence or been debarred from practice by reason of unprofessional conduct in any country and that to the best of my knowledge and belief no proceedings involving or likely to involve Date. a charge of offence or misconduct is pending against me in any country at present SIGNATURE B. THE FOLLOWING IS SUBMITTED IN SUPPORT OF MY APPLICATION A copy of my identity document or birth certificate. A copy of my marriage certificate should you wish to register in your married surname. Original confirmation issued by the educational institution confirming that you have complied with the requirements in respect of Diagnostic Privileges. Your name should appear on the lists posted on the HPCSA website as submitted by institutions to the Health Professions Council of South Africa* 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 Registration Number Amount I Dr Mr Mrs Miss Surname Receipt No* Maiden name if applicable First names No* Identity No* Postal address Reg* Date Postal code Residential address Tel H W Cell Fax Email Marital Status Race Asian Divorced African Married Coloured Gender Single White Male Female Country of origin I certify that the application meets the requirements as outlined in section B and that I have verified the Registration Officer hereby apply for recognition of Diagnostc privileges in Optometry and declare that I have complied with Signature I declare that I am the person referred to in the certificate below. I also declare that I have never been convicted of any criminal offence or been debarred from practice by reason of unprofessional conduct in any country and that to the best of my knowledge and belief no proceedings involving or likely to involve Date.

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Keywords relevant to Form 19

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  • Optometry
  • Pretoria
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  • dispensing
  • professions
  • REGISTRAR
  • TEL
  • Misconduct
  • GA
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  • Arcadia
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