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Application For Participation In Healthcare Network
HC Provider Type
-- Select Type --
Doctor
Radiology Center
Hospital
Medical Service Center
Pharmacy
Medical Supplier
Lab
Others
Personal Details
Family Name
Middle Name
First Name
Date of Birth
Sex
-- Select Sex --
Male
Female
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
- Select -
Yes
No
Remarks
Do you have internet connetion in the clinic
- Select -
Yes
No
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
Working Hours
Normal Days
From AM
00
01
02
03
04
05
06
07
08
09
10
11
00
05
10
15
20
25
30
35
40
45
50
55
To AM
00
01
02
03
04
05
06
07
08
09
10
11
00
05
10
15
20
25
30
35
40
45
50
55
From PM
12
13
14
15
16
17
18
19
20
21
22
23
00
05
10
15
20
25
30
35
40
45
50
55
To PM
12
13
14
15
16
17
18
19
20
21
22
23
00
05
10
15
20
25
30
35
40
45
50
55
During the month of Ramadan
From AM
00
01
02
03
04
05
06
07
08
09
10
11
00
05
10
15
20
25
30
35
40
45
50
55
To AM
00
01
02
03
04
05
06
07
08
09
10
11
00
05
10
15
20
25
30
35
40
45
50
55
From PM
12
13
14
15
16
17
18
19
20
21
22
23
00
05
10
15
20
25
30
35
40
45
50
55
To PM
12
13
14
15
16
17
18
19
20
21
22
23
00
05
10
15
20
25
30
35
40
45
50
55
Remarks
Please attach any supporting documents
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