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Registration Application Form For Foreigner
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Username
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Value required.
Minimum 4 characters
Please input text in latin
Password
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Minimum password is 8 characters
Registration Application Form
I apply for registration at national office of Cambodian Midwives Council
For one year registration only
For registration starting from date
From date:
*
Month
{{m}}
To Date:
*
Month
{{m}}
Section 1:
I APPLY FOR REGISTRATION WITH CAMBODIA MIDWIVES COUNCIL AS A
Graduate midwife
Midwife who has not been previously registered with this council
Other
Section 2: Personal Information
Name
Family Name
*
Value required.
First name
*
Value required.
Middle name
Previous /maiden name
Gender
*
Value required.
Male
Female
Date of Birth
*
Value required.
Day
{{d}}
Month
{{m}}
PLACE OF BIRTH
Country
*
Value required.
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OK
State/province
*
Value required.
{{$select.selected.label ? $select.selected.label : $select.search}}
OK
City
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OK
District/suburb
{{$select.selected.label ? $select.selected.label : $select.search}}
OK
Nationality
*
Value required.
Language
English
Other
If other specify your language
Value required.
CURRENT HOME ADDRESS
Country
*
Value required.
{{$select.selected.label ? $select.selected.label : $select.search}}
OK
State/province
*
Value required.
{{$select.selected.label ? $select.selected.label : $select.search}}
OK
City
{{$select.selected.label ? $select.selected.label : $select.search}}
OK
District/Suburb
{{$select.selected.label ? $select.selected.label : $select.search}}
OK
Street#
House#
Telephone number
*
Value required.
Invalid phone number
+855
E-mail address
*
Value required.
No Email
Please Enter Valid Email
