Basic Information Surname Given Names Sex MaleFemale Date of Birth Telephone Work Home Cell Fax Work Home Email Address Personal Work Address Home Address Work Address Medical Qualifications Type (Degree, Diploma, Etc.) Years Trained Institutions Date of Provisional Registration at MCJ Details of Practice Type of Practice GeneralSpecialistPrivate PracticeEmployed by Government Specialties CardiologyDermatologyENT SurgeryGastroenterologyGeneral SurgeryInternal MedicineNephrologyObstetrics & GynaecologyOrthopaedic SurgeryPaediatricsPlastic SurgeryRespiratory Other Type of Government Employment HospitalPrimary Care Additional Information Marital Status Hobbies & Interests Foreign Languages Medical Publications I agree to abide by the Regulations, By-Laws and the Rules of the Medical Association of Jamaica to which I may belong or with which I may at any time be associated (as the case may be) and to pay my annual subscriptions.