Med Reg PE P2 - Affirmative Portfolios

medical registration portal

WARNING! Please ensure that you have completed Part 1 before continuing. If you have not completed Part 1, please click here.

PORT ELIZABETH PART 2

PLEASE CONFIRM YOUR ID AND EMAIL (ensure it is the same as on Part 1)

Email *

ID/Passport *

BANKING DETAILS

Bank *

Name of Account Holder and relationship to assignee *

Account Type *

Account Number *

If you are registered with SARS, please provide your Tax Number *

DECLARATIONS

Declaration of Income *

If AP is my secondary source of income, I understand and accept that AP will not be liable for any shortfall in taxation upon assessment at the end of the financial year and the onus is on me to make provision for any such shortfall. I hereby request AP to tax my salary as follows *

If AP is my secondary source of income and I selected to specify the percentage to be taxed. I hereby request AP to tax my salary at the following percentage (specify %)

Declaration Details (Employment)

Please complete the relevant information

SANC / HPCSA Professional Indemnity Organisation

I am also registered with another agency (name of agency)

I am permanently employed (name of employer)

SANC Ref No / HPCSA No *

Declaration Details (Other)

Declaration Details (Criminal)

Please complete the relevant information

If you have any prior criminal convictions against your name, please provide details of the charges with the date convicted and the sentence

If you have any criminal cases pending against your name, please provide details of the cases with the date committed and the offence

EMERGENCY CONTACTS

Provide contact details of 2 of your next of kin for emergencies. Please include:
1. Name
2. Their relationship to you
3. Telephone numbers (home, work and cell) *

REFERENCES

Please provide contact details of 3 referees. Please include

Company Name,
Contact Person Name with Position and Contact Number,
Your Position at this Company,
Start and End Date of your employment at this Company,
Your Reason for Leaving

Referee 1

Referee 2

Referee 3

CV/RESUME AND SUPPORTING DOCUMENTS

Upload Your CV (MS Word or PDF) *

SANC Receipt and/or eRegister – 1MB size restriction *

SANC Registration (ensure paid up) – 1MB size restriction *

ID Book (certified) – 1MB size restriction *

Bank Statement / Bank Letter – 1MB size restriction *

Certificates (combine in ONE file if you want to submit multiple certificates) – 1MB size restriction *

Proof of Indemnity Cover *

Hepatitis B Inoculation Certificate *

Department of Health Letter on Remunerative Work Outside the Public Service (RWOPS) (if applicable) *

AP BRANCH USED FOR REGISTRATIONS

Office (AP Branch) *

CHECKLIST

Registration Checklist *

POPIA COMPLIANCE

I agree to the Terms and Conditions *

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