1964_MEDICAL_PRACTITIONERS_(REGISTRATION_AND_DISCIPLINARY_PROCEDURE)_REGULATIONS — Page 21

1982 Ed.]

Medical Practitioners ( Registration and [CAP. 161

Disciplinary Procedure) Regulations

A 21

[Subsidiary]

3. I hold the following qualifications--

and have had the experience described in the Medical Registration Ordinance.

Declared at *

this.......... day of

19..........

Before me,

Commissioner for Oaths

or

Notary Public.

*Insert place of residence of applicant.

Photograph

FORM 4

THE MEDICAL COUNCIL OF HONG KONG

MEDICAL REGISTRATION ORDINANCE (Chapter 161)

MEDICAL PRACTITIONERS (REGISTRATION AND DISCIPLINARY PROCEDURE) REGULATIONS

CERTIFICATE OF REGISTRATION

[reg. 7.]

I hereby certify that the following is a true copy of particulars extracted from the entry in the Register---

Name

Address

Date of registration

Qualifications

Fee paid: $450.

or free for the reason stated below-

Registrar.

19........

G.N.A. 20-62. L.N. 3/76.