WESTERN SAMOA

THE MEDICAL PRACTITIONERS (FEES AND FORMS) REGULATIONS 1977
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HIS HIGHNESS, MALIETOA TANUMAFILI II, HEAD OF STATE
At the Government House at Apia this 10th day of June 1977

PURSUANT to the Medical Practitioners Act 1975, the Head of State, acting on the advice of Cabinet, hereby makes the following regulations.

ANALYSIS
l. Title and commencement 
2. Interpretation
3. Registers 
4. Application for registration
5. Certificate of registration
6. Certificate of provisional registration
7. Practising certificates
8. Fees

Schedules
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REGULATIONS

1. Title and commencement - (1) These regulations may be cited as the Medical Practitioners (Fees and Forms) Regulations 1977. 

(2) These regulations shall come into force on the date which they are made.

These Regulations were gazetted on 1 July 1977, W.S. Gazette 1977, Vol. VII, No. 7, p. 749.

2. Interpretation - In these regulations, unless the context otherwise requires, -

"Act" means the Medical Practitioners Act 1975: 

"Council" means the Medical Council established by the Act:

"Registration" includes provisional registration: 

"Secretary" means the Secretary to the Council.

3. Registers - (1) The Secretary shall set up and keep each class of persons referred to in section 10 of the Act to be registered under the Act.

(2) Each such register, with the appropriate title and necessary modifications, shall be in Form 1 set out in the First Schedule.

4. Application for registration - Every application for registration shall be made in Form 2 set out in the First Schedule.

5. Certificate of registration - A certificate of registration under the Act shall be in Form 3 set out in the First Schedule.

6. Certificate of provisional registration - A certificate of provisional registration under the Act shall be in Form 4 set out in the First Schedule.

7. Practising certificates - (1) A temporary practising certificate to be issued under section 16 of the Act shall be in Form 5 set out in the First Schedule.

(2) An annual practising certificate issued to any person who is provisionally registered under the Act shall be in Form 6 set out in the First Schedule.

(3) An annual practising certificate issued to any person who is registered under the Act shall be in Form 7 set out in the First Schedule:

Provided that where such a certificate is issued to a person practising medicine or surgery in a private capacity, the certificate shall be engrossed on its face as follows:

"And is entitled under this certificate to practise in a private capacity."

8. Fees - The fees prescribed in the Second Schedule shall be paid to the Council in respect of the matters specified in that Schedule.
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SCHEDULES
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FIRST SCHEDULE

Regulation 3
Form 1

Register of Medical Practitioners

(or appropriate title for each class of persons referred to in section 10 of the Act)

Date of registration: ................................................................................
Name:.......................................................................................................
Address: ...................................................................................................
Qualifications: ..........................................................................................
Date of issue of certificate of registration: ...............................................
Date of issue of annual practising certificate: ..........................................
Date of amendment of register: ................................................................
Nature and particulars of amendment
(e.g., additional qualifications): ............................................................
New address: .............................................................................................
Date of correction of register:....................................................................
Nature and particulars of correction: ........................................................
(As appropriate) Transfer of register - Date: ................................
New register: .................................................................................
Date of suspension from register:...............................................................
Grounds for suspension: ............................................................................
Date of removal from register: ..................................................................
Grounds for removal:.................................................................................
Date of re-registration: ..............................................................................
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Form 2

Regulation 4

Application For Registration

(or provisional registration) under the Medical Practitioners Act 1975.

The Secretary, 
Medical Council, 
APIA.

Application is hereby made for registration (or provisional registration) (delete as appropriate) as a medical practitioner under the provisions of the Medical Practitioners Act 1975. I submit the following particulars:-

1. Full name: ..........................................(Surname first - Block letters) 

2. Address: ................................ Residence: ........................................
Work or practice: .................................................................................

3. Date of birth: .....................Place of Birth………………………….

4. Qualifications, conferring authority and year of issue of each degree, diploma, certificate etc.:……………………………………………
(State all qualifications) 

5. History of work or practice since qualifying:

Place	Date	
	From	To	

_____________________________________________________________
(Complete on separate sheet if space insufficient)

6. Reasons for being in Western Samoa:………………………………………

7. Countries where now registered as medical practitioner:
…………………………………………………………………………………

8. I have not at any time been removed from any register of medical practitioners in any country where I am or have been registered. (If so removed, state the date and reasons for removal): …………………………………………………………………………………..
…………………………………………………………………………………………….

9. I enclose: (a) 2 current references as to my good character and reputation given by:
…………………………………………………………………………………….(Name)
………………………………………………………………………………(Designation)
…………………………………………………………………………………  (Address)
and, 
.................................................................................................................................(Name)
………………………………………………………………………………(Designation)
…………………………………………………………………………………..(Address)

(b) the fee of $ .....................................................................................................................

I HEREBY CERTIFY that I am the person applying for registration( or provisional registration) as a medical practitioner in Western Samoa, and that I am the person named in the above degrees, diplomas, certificates, etc. (delete or add as appropriate), and that the information I have given above is true and correct.

DATED AT ………………..this ……………day of………………..19………………………
…………………………….
(Signature of Applicant)

NOTE: Under the Medical Practitioners Act 1975, the Council in its discretion may require evidence, other than those submitted, of the applicant's qualifications and practical experience; and may examine on oath the applicant or any other person with respect to the application; or may require the applicant verify by statutory declaration any statement made by him in his application.
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Form 3

Regulation 5

Certificate of Registration under The Medical Practitioners Act 1975

I HEREBY certify that…………………………………………………is registered as a medical practitioner, h………………………….name having been duly entered in the register of Medical Practitioners of Western Samoa on the……...day of……………….19…………

DATED at Apia this …………………day of…………………..19……………………………
…….……………………………….
(Secretary to the Medical Council)
Signature of holder:……………………..
………………………………………….
………………………………………….
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Form 4

Regulation 6

Certificate of Provisional Registration under the Medical Practitioners Act 1975

I HEREBY certify that…………………………………………………is provisionally registered as a medical practitioner, h………………………….name having been duly entered in the register of Provisionally Registered Medical Practitioners of Western Samoa on the…………………..day of……………………………………………19…………

DATED at Apia this …………………day of…………………..19……………………………
…….……………………………….
(Secretary to the Medical Council)
Signature of holder:……………………..
………………………………………….
………………………………………….
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Form 5

Regulation 7(1)

Temporary Practising Certificate

(Issued under section 16 of the Medical Practitioners Act 1975)

I HEREBY certify that…………………………………………………is entitled to practice
………………* in Western Samoa.
THIS certificate shall be valid for 3 months from the date of issue and is in force until the………………………..day of……………………………19……………………..
unless before that date the abovementioned has been duly registered or this certificate has been cancelled.

ISSUED at Apia this…………………….day of………………19………………………
…………………………
for: (Director of Health)
(The Medical Council) 

* (Insert medicine, or surgery, or both)
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Form 6

Regulation 7(2)

Annual Practising Certificate of Provisionally Registered Medical Practitioner

I HEREBY certify that…………………………………………………is provisionally registered as a medical practitioner in Western Samoa under the provisions of the Medical Practitioners Act 1975 and is entitled to practise…………………………………………*
in the hospital at……………….until the 31st of December 19…………………………….

DATED at Apia this …………………day of…………………..19……………………………
…….……………………………….
(Secretary to the Medical Council)
(* Insert medicine, or surgery, or both)

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Form 7

Regulation 7(3)

Annual Practising Certificate of Registered Medical Practitioner

I HEREBY certify that…………………………………………………is provisionally registered as a medical practitioner in Western Samoa under the provisions of the Medical Practitioners Act 1975 and is entitled to practise…………………………………………*
until the 31st of December 19…………………………….

DATED at Apia this …………………day of…………………..19……………………………
…….……………………………….
(Secretary to the Medical Council)
(* Insert medicine, or surgery, or both)
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SECOND SCHEDULE
Regulation 8

Fees	$	
		
On application for registration……………………………………………	10.00	
On application for provisional registration……………………………….	5.00	
For certificate of registration (whether provisional or full registration)……………………………………………………………….	
2.00	
For annual practising certificate (whether registered or provisionally registered)…………………………………………………………………	
2.00	
For any inspection of any register………………………………………...	1.00	

MALIETOA TANUMAFILI II
HEAD OF STATE
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