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Type of Healthcare Facility
Clinic
Hospital
Dental
Pharmacy
Veterinary
Others
Healthcare Facility Name
Healthcare Facility Address 1
Healthcare Facility Address 2
Healthcare Facility Address 3
Healthcare Facility Address 4
Healthcare Facility Postcode
Healthcare Facility State
Federal Territory of Kuala Lumpur
Federal Territory of Labuan
Federal Territory of Putrajaya
Johor
Kedah
Kelantan
Malacca
Negeri Sembilan
Pahang
Perak
Perlis
Penang
Sabah
Sarawak
Selangor
Terengganu
Applicant Name
Applicant Position
Telephone Number
Fax number
Email
Company Name
Business Registration No
Year of Incorporation
Details of Directors/Partners/Proprietor 1
Identification Number 1
Details of Directors/Partners/Proprietor 2
Identification Number 2
Details of Directors/Partners/Proprietor 3
Identification Number 3
Details of Directors/Partners/Proprietor 4
Identification Number 4
Mayflax Sales Representative
Not applicable
David
Jimmy
May
Annual Practicing Certificate Or Equivalent (up to 2 attachments)
Identification Card Copy - Front
Identification Card Copy - Back
SSM Company Profile
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