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    Annex D - Application For Registration of Physician Form

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    prettyjeany
    This document is an application form for physicians to register with the Land Transportation Office (LTO) in the Philippines. It requests information such as the physician's name, clinic details, contact information, specialization, and certification documents. Upon submission of required documents including photos, fingerprints, and certification, an authorized LTO personnel can approve and register the physician in the system.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Annex D - Application For Registration of Physician Form

    Uploaded by

    prettyjeany
    650 views4 pages
    This document is an application form for physicians to register with the Land Transportation Office (LTO) in the Philippines. It requests information such as the physician's name, clinic details, contact information, specialization, and certification documents. Upon submission of required documents including photos, fingerprints, and certification, an authorized LTO personnel can approve and register the physician in the system.

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    Annex D - Application for Registration of Physician Form

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    This document is an application form for physicians to register with the Land Transportation Office (LTO) in the Philippines. It requests information such as the physician's name, clinic details, contact information, specialization, and certification documents. Upon submission of required documents including photos, fingerprints, and certification, an authorized LTO personnel can approve and register the physician in the system.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    650 views4 pages

    Annex D - Application For Registration of Physician Form

    Uploaded by

    prettyjeany
    This document is an application form for physicians to register with the Land Transportation Office (LTO) in the Philippines. It requests information such as the physician's name, clinic details, contact information, specialization, and certification documents. Upon submission of required documents including photos, fingerprints, and certification, an authorized LTO personnel can approve and register the physician in the system.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    Republic of the Philippines

    Department of Transportation
    LAND TRANSPORTATION OFFICE
    Photo of A
    APPLICATION FOR REGISTRATION OF PHYSICIAN

    CLINICAL INFORMATION
    Clinic Name
    Address
    Medical Clinic Accreditation Number
    PHYSICIAN INFORMATION
    Last Name Sex Female Male
    First Name Email Address
    Middle Name Contact No.
    Birth Date PRC No.
    Month Day Year Specialization (if any)

    Signature over Printed Name Date


    Indorsed by:

    Signature over Printed Name of Owner/Authorized Representative Date


    To be filled out by LTO Authorized Personnel

    Documents Submitted by Applicant:

    Two pieces 2x2 photo with name tag within the last three months Clinic Code
    from the date of application for registration;
    Certified true copy of Certificate of Registration duly issued by Username
    the Board of Medical Examiners;
    Certificate of Membership and good standing from the Medical
    Association of its component society;
    Certificate of good standing from the Professional Regulation Registered by:
    Commission;
    Photocopy of the valid Professional Regulation Commission
    license card (original copy presented during registration);
    Copy of valid government issued identification card (other than LTO Authorized Personnel
    PRC) with photo and signature (original copy presented during (Printed Name & Signature)
    registration);
    Current Professional Tax Receipt (PTR) number except for
    government physician;
    Taxpayer's Identification Number (TIN);
    Digital Photograph and Biometric Scan of the Physician;
    For government physicians, certified true copy of approved
    appointment or Certificate of Employment issued by the agency;
    For government physicians who desire to engage in private
    practice, Authority to Engage in the Private Practice of Profession
    approved by the Head of Agency where he/she is employed.

    Approved by: Date:

    LTO Authorized Signatory


    (Printed Name & Signature)

    Fingerprint Impression (must be taken immediately after registration)


    Right Thumb Right Index Finger Right Middle Finger Right Ring Finger Right Little

    Left Little Finger Left Ring Finger Left Middle Finger Left Index Finger Left Thu
    Photo of Applicant

    Male

    Date

    Date

    Date:

    ation)
    Right Little Finger

    Left Thumb

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