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Medical Practitioner Registration


Guide:   Please make sure the column with * mark is fill completely

Medical Practitioner Information
Medical Practitioner Type  *
Medical Practitioner Name  *
Passport No.  
(mandatory for foreigner medical practitioner)
Nationality  *
Have Master/Diploma/Certificate in Occupational Health/Medical  *
Shipping Familiarization Course Date
(input in format dd/mm/yyyy)
Years Of Experience In The Medical field  *
(year)

Clinic Information
Clinic Name   *
Address  *
Postcode  *
City  *
State  *
(fill-in this field if state is others)
Country  *
Phone No.  *
Fax No.
Email

Agent Name *
Company Name *
Address *
Phone No. *
Fax No.
Email

Payment Information
Payment (RM)

Supported Document
Medical Practitioner Photo   *
[Remove]  (No file),  0 KBytes  (Max. 50 KBytes)
Certificate/Diploma (Occupational/Medical)   *
[Remove]  (No file),  0 KBytes   (Max. 200 KBytes)

     


  


  

Agreement  *