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Get ZA HPCSA Form 10

, this form must be completed and returned to: The Registrar, Medical and Dental Professions Board, P O Box 205, Pretoria, 0001 NAME OF APPLICANT (Full names): NAME OF ACCREDITED FACILITY: POSTAL ADDRESS: TITLE, INITIALS AND SURNAME OF CONTACT PERSON: I, the undersigned, CEO/Chief Medical Superintendent of the above facility, hereby certify that the said intern completed internship training in the specified departments/domains of this facility for the periods specified, that he or she fulfilled .

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