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	Practice Particulars
	PHMC License Number *
	Type of Practice *	<-- Select Practice Type --> GP Clinic Institution Locum Polyclinic Private Dental Clinic Specialist Clinic Others
	Clinic Name *
	Clinic Address *
	Postal Code *
	Clinic Manager (Doctor-in-charge) Details
	Family Name *
	Given Name *
	Gender *	Male Female
	NRIC/Passport/FIN Number *	[e.g. S0040310E]
	Document Type *	Singapore Citizen Singapore PR Work Permit Holders Employment Pass Holders Others
	Nationality	Singapore Afghanistan Albania Algeria Argentina Australia Austria Belgium Brazil Bulgaria Canada Chile China Colombia Costa Rica Croatia Czech Republic Denmark Ecuador Egypt El Salvador Finland France Germany Greece Hong Kong Hungary India Indonesia Ireland Israel Italy Japan Jordan Korea, South Lebanon Malaysia Mauritius Mexico Morocco Netherlands New Zealand Norway Pakistan Peru Philippines Poland Portugal Puerto Rico Romania Russia Saudi Arabia South Africa Spain Sweden Switzerland Taiwan Thailand Turkey Ukraine United Arab Emirates United Kingdom United States of America Venezuela Yugoslavia (Former) [Other]
	Date of Birth *	Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
	MCR Number *
	Email * [All replies will be sent to this email address]
	Contact Type - Number *	Home Office HandPhone Pager Fax -
	Speciality Registered with SMC
	GPEP Member If you are not a GPEP Member, click here to find out more.	Yes   No
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	User Password *	[Min. 8 characters]
	Confirm Password *	[Min. 8 characters]