Paediatrician's Registration

 

Registration Form
Title:
Surname:
First Name:
Other Names:
Gender: Male Female
   
Fellowship Obtained: WACP FMCP Others
PAN Registration: Yes No
MembershipID:
Year of Fellowship:
   
Work Area: Public Hospital
Private Hospital
Company Hospital
Nigerian Government Agency
International Agency e.g. WHO, UNICEF etc
NGO
Others
   

What Level of facility are you working if in a health setting?:
  Primary Secondary Tertiary
Name of Health Institution(s):
 
Location of Institution  
City:
LGA:
State:
Country:
Practicing Subunit/
Area of Interest:
   
PAN Office Participation Details
Ever held office in PAN? : Yes No
PAN Office Post Held:
Time:
   
Email:
Telephone1:
Telephone2: