February 21, 2018

Affiliate Medical Officer Registration


All information submitted are for administration & legal purposes and will remain confidential

All information submitted are for administration & legal purposes and will remain confidential

All information submitted are for administration & legal purposes and will remain confidential

  • Personal Info
  • Professional Info
  • Affiliation Preferences

Identity

First Name

Middle & Last Name

Date of Birth

Please upload a scanned active Identity Card (KTP) in .JPG format

Contact

Email

Phone

Address

City

Country

Professional History

Which of the following describes you?

Which university did you graduate from?

Year of graduation

Please upload your scanned active STR in JPG format

Professional History

Are you currently employed full time at a hospital/clinic?

Which healthcare point(s) are you currently employed at?

Name of your current employment company

Affiliation Preferences

Where would you like to take this affiliate-ship of ours?

How much would you like to earn in a month from our affiliate-ship?

Commissions & Fees

Where should we transfer your earnings?

Account Number

Please upload your scanned tax number (NPWP) in .JPG format