GENERAL INFORMATION
Personal Information
Full Name *

Nationality * Select - Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire Bosnia and Herzegovina Botswana Brazil British Indian Ocean Ter Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canary Islands Cape Verde Cayman Islands Central African Republic Chad Channel Islands Chile China Christmas Island Cocos Island Colombia Comoros Congo Cook Islands Costa Rica Cote DIvoire Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Ter Gabon Gambia Georgia Germany Ghana Gibraltar Great Britain Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guyana Haiti Hawaii Honduras Hong Kong Hungary Iceland Indonesia India Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea North Korea South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malaysia Malawi Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Midway Islands Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Nambia Nauru Nepal Netherland Antilles Netherlands (Holland, Europe) Nevis New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Norway Oman Pakistan Palau Island Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Republic of Montenegro Republic of Serbia Reunion Romania Russia Rwanda St Barthelemy St Eustatius St Helena St Kitts-Nevis St Lucia St Maarten St Pierre and Miquelon St Vincent and Grenadines Saipan Samoa Samoa American San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Tahiti Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Is Tuvalu Uganda United Kingdom Ukraine United Arab Emirates United States of America Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Virgin Islands (Brit) Virgin Islands (USA) Wake Island Wallis and Futana Is Yemen Zaire Zambia Zimbabwe

Date of Birth *

Gender * Select Male Female

Mobile Number *

Email *

City *

Institution/ Facility Name *

General specialty *

sub-specialty *

Years of experience (as a consultant or equivalent) *

Have you ever participated in accreditation evaluation visits * Select Yes No

Attending the Faculty development workshop * Select Yes No

Number of times participating in visits *

Are you NIHS scientific committee member? * Select Yes No

Curriculum Vitae *

practice license (if applicable)

Recommendation letter from DIO ( or relevant ) Members Of NIHS Scientific Committee are exempted

Have a current photo ready in png or jpg format *

Statement letter to explain his or her interest *

Attach Copy of Emirates ID (for UAE Residents) *

Conflict of interest form * Please download Conflict of Interest Form (click here) and upload the signed form as an attachment

I hereby declare that the information I have provided in this application form and attached as supporting evidence are true. I understand that for this application to be successful, I must comply with the registration requirements set out by National Institute for Health Specialties Accreditation Rules. I understand that my application may be refused or cancelled if I do not provide the necessary evidence or fail to provide true and correct information in this application. If my application is accepted by NIHS, I commit to provide minimum of five days per year for conducting accreditation site visits.