Medical Council of Guyana

                 APPLICATION FOR REGISTRATION


Name_________________________________________________________
        Surname          First Name          Other

Date Of Birth_________________ Sex_________ Phone No.________

Address______________________________________________________
         No. Street                 Dist./Ward

       ______________________________________________________
         Town/Village              Region

Nationality__________________________________________________

Marital Status_______________________________________________

Type Of Registration:
          Full____________   Institutional___________
          Internship______   Short Term___X_______
          D.D.S. Temporary___________

Qualifications ______________________________________________
               Degree    University     Country   Year

Specialty____________________________________________________
          Type                Country             Year