Hong Kong Regulations

OPTOMETRISTS (REGISTRATION AND DISCIPLINARY PROCEDURE) REGULATION - SCHEDULE 1

FORM OF REGISTER

[section 3]

SUPPLEMENTARY MEDICAL PROFESSIONS ORDINANCE

(Chapter 359)

OPTOMETRISTS (REGISTRATION AND DISCIPLINARY PROCEDURE) REGULATION

Register of Optometrists

PART I

REGISTRATION NO. :
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NAME : ...................................................................(
)

ADDRESS :
...........................................................................
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BUSINESS ADDRESS :
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QUALIFICATIONS AND DATE OBTAINED :
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DETAILS OF WORKING EXPERIENCE :
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CERTIFICATE OF REGISTRATION SERIAL NO. :
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DATE OF REGISTRATION :
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REMARKS :
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Photograph

.............................................
Secretary,
Optometrists Board.

PART II

REGISTRATION NO. :
...........................................................................
........................

NAME : ...................................................................(
)

ADDRESS :
...........................................................................
........................

BUSINESS ADDRESS :
...........................................................................
........................

QUALIFICATIONS AND DATE OBTAINED :
...........................................................................
........................

...........................................................................
........................

DETAILS OF WORKING EXPERIENCE :
...........................................................................
........................

...........................................................................
........................

CERTIFICATE OF REGISTRATION SERIAL NO. :
...........................................................................
........................

DATE OF REGISTRATION :
...........................................................................
........................

REMARKS :
...........................................................................
........................

...........................................................................
........................

Photograph

.............................................
Secretary,
Optometrists Board.

PART III

REGISTRATION NO. :
...........................................................................
........................

NAME : ...................................................................(
)

ADDRESS :
...........................................................................
........................

BUSINESS ADDRESS :
...........................................................................
........................

QUALIFICATIONS AND DATE OBTAINED :
...........................................................................
........................

...........................................................................
........................

DETAILS OF WORKING EXPERIENCE :
...........................................................................
........................

...........................................................................
........................

CERTIFICATE OF REGISTRATION SERIAL NO. :
...........................................................................
........................

DATE OF REGISTRATION :
...........................................................................
........................

REMARKS :
...........................................................................
........................

...........................................................................
........................

Photograph

.............................................
Secretary,
Optometrists Board.

PART IV

REGISTRATION NO. :
...........................................................................
........................

NAME : ...................................................................(
)

ADDRESS :
...........................................................................
........................

BUSINESS ADDRESS :
...........................................................................
........................

QUALIFICATIONS AND DATE OBTAINED :
...........................................................................
........................

...........................................................................
........................

DETAILS OF PROVISIONAL WORKING EXPERIENCE :
...........................................................................
........................

...........................................................................
........................

CERTIFICATE OF REGISTRATION SERIAL NO. :
...........................................................................
........................

DATE OF REGISTRATION :
...........................................................................
........................

REMARKS :
...........................................................................
........................

...........................................................................
........................

Photograph

.............................................
Secretary,
Optometrists Board.

(Enacted 1994)