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Country
 
HC Provider Type
  Personal Details  
Family Name
Middle Name
First Name
Date of Birth Click Here to Pick up the date 
Sex
Nationality
National ID Number
  Mailing Address  
P. O. Box
City
Zip Code
Remarks
  Work Location  
Street Name
Building Number
Building Name
Area
City
Any Land Marks
  Contact Information  
Work Phone (1)
Work Phone (2)
Work Fax
Home Phone (1)
Home Phone (2)
Home Fax
Mobile Number
e-mail Address
Web Address
Do you have a personal computer at the place of work
Remarks
Do you have internet connetion in the clinic
  Financial & Legal Information  
Account Holder Name
Bank Name
Branch
Account Number
  Specialty  
Specialty (1)
University Name
Certificate Description (1)
Specialty (2)
University Name
Certificate Description (2)
Specialty (3)
University Name
Certificate Description (3)
Specialty (4)
University Name
Certificate Description (4)
  Practice & Permissions  
Type of Practice
Practice Permission Number
Practice Permission Date Click Here to Pick up the date 
  Working Hours  
Normal Days
From AM To AM From PM To PM
 
During the month of Ramadan
From AM To AM From PM To PM
 
Remarks
Please attach any supporting documents
 
 
 
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