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LEMBAGA JURURAWAT MALAYSIA NURSING BOARD MALAYSIA

KEMENTERIAN KESIHATAN MALAYSIA MINISTRY 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

Tel : 03-88831355 Fax : 03-88831329 Setiausaha, BHG.11 - SEKSYEN 12 (1 ) Lembaga Jururawat Malaysia,Kementerian Kesihatan Malaysia, Aras 3, Blok E1, Parcel E,Pusat Pentadbiran Kerajaan Persekutuan,62590 Putrajaya.Tarikh: PERMOHONAN PENGEKALAN NAMA 1. Nama: .2. No. Pendaftaran: 3. No. KP : .. (Baru) (Lama)4. Gelaran Jawatan: 5. Alamat Rumah : ... Talipon: . (Rumah) ..........(Pejabat) .....(HP)6. Tempoh Pengekalan Nama dipohon: Dari Hingga (Maksima 3 tahun) Tanda di kotak yang berkenaan: Baru Ulangan7. Sebab sebab permohonan diperlukan : .i) Berikan sebab jika bekerja di luar negara : .........ii) Alamat hospital bertugas di luar negara : ....... Bayaran :..Tandatangan :..Tarikh :.. Nota: 1 Sila lampirkan salinan APC / surat Pengekalan Nama yang terakhir 2 Pembayaran - RM 25.00 setahun - Jururawat Terlatih - RM 10.00 setahun - Jururawat Masyarakat / Penolong Jururawat 3 Bayaran hendaklah dibuat melalui kiriman WANG POS atau BANK DERAF sahaja dan di bayar kepada Setiausaha Lembaga Jururawat Malaysia.

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