application_for_retention_of_name_-_english_and_malay_version.

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LEMBAGA JURURAWAT MALAYSIA
URSING BOARD MALAYSIA
KEMENTERIAN KESIHATAN MALAYSIA
INISTRY OF HEALTH MALAYSIA
ARAS 3, BLOK E1, PARCEL E
LEVEL 3,BLOCK E1, PARCEL E
PUSAT PENTADBIRAN KERAJAAN PERSEKUTUAN
FEDERAL GOVERNMENT ADMINISTRATIVE CENTRE
62590 PUTRAJAYA
BKJ -BOR-DAF/APC-03
T e l
: 03-88906025
F a x
: 03-88831329
Secretary,
DIVISION 11 - SECTION 12 (1)
Nursing Board Malaysia, Ministry Of Health Malaysia, Level 3, Block E1 Parcel E Federal
Government Administrative Centre 62590 Putrajaya. Date:



APPLICATION FOR RETENTION OF NAME.
1. Full Name
2.Registration Number: ..
3. Identity Card No./ Passport
4. Designation:
5. Home Address
..
.
6. Telephone No: House)(Mobile).
7. Application Period:
From.Till..
8. Reason for Application:..
i) Give the reason to work abroad.
ii) Hospital address abroad
..
..
Total payment:
Signature:
Date:
D a t e : 1 E a c h A p p l i c a t i o n m u s t b e
a c c o m p a n i e d b y a P h o t o s t a t c o p y o f N u r s e
R e g i s t r a t i o n C e r t i f i c a t e / c u r r e n t A n n u a l
P r a c t i c i n g C e r t i f i c a t e ( M a l a y s i a ) 2 . P a y m e n t o f
- R M 2 5 . 0 0 p e r y e a r

R e g i s t e r e d N u r s e - R M - 1 0 . 0 0 p e r Y e a r

R e g i s t e r e d C o m m u n i t y N u r s e / A s s i s t a n t
N u r s e 3 . P a y m e n t t o b e m a d e v i a P o s t a l O d e r
o r B a n k D r a f t o n l y a n d t o p a y t o t h e S e c r e t a r y
o f N u r s i n g B o a r d M a l a y s i a .