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BKJ -BOR-14

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)

Contact No: 6. Application period: From Till. .

(Maximum 3 years) Put thick (..J) the appropriate box: New Application 7. Reason for application:

D
.

Repeat application

D
.

i) Give the reason to work abroad: ii) Hospital address abroad:

'" .

Total payment Signature Date: Note: 1 2

. . .

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.

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