HKIA Registration Online Application

HKIA Registration Application Form

I. Personal Information

Title *

DrMissMrMrsMs

Family Name *As printed on HKID or equivalent ID document

Given Name *As printed on HKID or equivalent ID document

中文姓名 Chinese Name (if applicable)

Nationality

Email *

Contact Phone *

Mobile Phone *

Fax

Permanent Address *

II. Work Information

Organisation Name *

機構名稱(中文)

Job Position *

Job Description *

Phone *

Fax

Address *

機構地址(中文)

Length of Practice as Audiologist after Acquiring the Professional *

(years)

III. Correspondence Address

Address *

Same as permanent addressSame as organisation addressOther (please specify below)

Address

IV. Academic Qualification

Highest Academic Qualification *

Institution *

Year Obtained *

Relevant Professional Qualification in Audiology

Year Obtained

Institution

Clinical Practicum *

Included in the Postgraduate ProgrammePassed an examination on clinical competence of audiology practiceObtained the right of audiology practice where the professional qualification was acquired (please specify below)

Obtained the right of audiology practice in please specify where your professional qualification was acquired

Supplementary Information

V. Continuing Professional Development

No. of Continuing Professional Development (CPD) Hours obtained in the Past 12 Months in activities recognised by HKIA *

VI. Professional Indemnity Insurance Coverage

Do I have valid and individually named professional indemnity insurance coverage? *

Yes, I have valid and individually named professional indemnity insurance coverage.No, I do not have valid and individually named professional indemnity insurance coverage.

VII. Declaration

Declaration 1 *

I have provided true copy of all documents required for application for registration in the Register held by the Hong Kong Institute of Audiologists Limited.

Declaration 2 *

I agree to have my name and accreditation status disclosed through the Register and the HKIA website.

Declaration 3 *

I agree to comply with the Code of Ethics for Audiologist in Hong Kong.

Declaration 4 *

I declare that the information given in this application is correct to the best of my knowledge and belief.

Please read the Quick Application Guidelines before filling in the form.