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Title: PERATURAN-PERATURAN PENDAFTARAN AHLI FARMASI 2004 - Borang 11
Date: 15-Sep-2004
Category: Others

AKTA PENDAFTARAN AHLI FARMASI 1951

 

PERATURAN-PERATURAN PENDAFTARAN AHLI FARMASI 2004

Borang 11

(Peraturan 12)

PERMOHONAN BAGI PENGEKALAN DALAM DAFTAR  PERTUBUHAN PERBADANAN

1.    Maklumat pemohon:

       (a)  Nama penuh:..............................................................................

       (b)  No. kad pengenalan: .................................................................

       (c)  Jawatan........................................................................................

 

2.    Maklumat pertubuhan  perbadanan:

       (a)  Nama: .........................................................................................

       (b)  Alamat perniagaan utama:  

.......................................................................................................

            .......................................................................................................

       (c) Alamat-alamat cawangan seperti dilampirkan (jika ada):    

           ........................................................................................................

           .........................................................................................................

       (d)  No. sijil tahunan akhir: ....................................................................

 

3.    Maklumat penguasa:

       (a)  Nama:.............................................................................................

       (b)  No Sijil Pendaftaran: ......................................................................

 

4.     *Cek/kiriman pos/kiriman wang  No:..................................berjumlah RM200.00.

 

Tarikh:......................................                                               .......................................

                                                                                      Tandatangan pemohon

*potong mana-mana yang tidak berkaitan.


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