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NURSING BOARD MALAYSIA MINISTRY OF HEALTH MALAYSIA LEVEL 3, BLOCK E1, PARCEL E FEDERAL GOVERNMENT ADMINISTRATIVE CENTRE
62590 PUTRAJAY A
Tel Fax
03-88831320 03-88831329
Secretary Nursing Board Malaysia, Ministry of Health Malaysia Level 3, Block E1 Parcel E, Federal Government Administrative Centre, 62590 Putrajaya. Date: APPLICATION 1. 2. 3. 4. 5. Name: Registration Number: Identity Card No. / Passport No: : Designation: Home Address : . . FOR RETENTION OF NAME
DIVISION 11
- SECTION 12 (1)
(Maximum 3 years) Put thick (..J) the appropriate box: New Application 7. Reason for application:
D
.
Repeat application
D
.
'" .
. . .
Please attach copy of APC / latest Letter Retention of Name Payment - RM 25.00 per year- Registered Nurse - RM 10.00 per Year - Registered Community Nurse / Assistant Nurse
Payment by MONEY ORDER or BANK DRAF ONL Y (Malaysian Currencies) and payable to Secretary Nursing Board Malaysia.