Registration Form

First Time Registration Form

Issue of CME Registration Cards
to Physicians and Dentists

The CME Registration Card will be ready for collection 3 days after your application is received.

1. Personal Information
First Name:	Middle Name:	Surname:

Sex: Male Female

Mailing Address:

Tel No.:	Fax No.:
Email address:	Mobile/Pager:

2. Qualifications
A.	Degree/Certificate:
	Institution:
	Year obtained:

B.	Degree/Certificate:
	Institution:
	Year obtained:

C.	Degree/Certificate:
	Institution:
	Year obtained:

D.	Degree/Certificate:
	Institution:
	Year obtained:

E.	Degree/Certificate:
	Institution:
	Year obtained:


Specialty:
Sub-specialty:

3. Employment Information
Date of Employment: (Date/Month/Year)
Professional Status:
Name of Hospital/Institution:
Employer Category:
Address:

ID No. Issued by Ministry of Health/University/Licence No.:
Email address:	Fax No.:	Tel. No.:

IMPORTANT
If you wish to re-enter data, press Reset. Please press Submit only once.
Your application will be processed and you will receive a message indicating the data you submitted. Please print this data sheet and keep the printout for future reference.
Contact the CME center at Fax: 22467140 or email: cmecenter@kims.org.kw to confirm your application has been received.

I hereby certify that the information mentioned above is true.

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