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PHARMACY REGISTRATION
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PERSONAL DETAILS // INFORMASI PERIBADI
Registration for infant (Below 1 year old)? // Pendaftaran untuk kanak-kanak (dibawah 1 tahun)?
*
YES // YA
NO // TIDAK
Full Name // Nama Penuh
*
First
Last
Age // Umur (Months / Bulan)
*
Age // Umur
*
Date of Birth // Tarikh Lahir
*
Day//Hari
1
2
3
4
5
6
7
8
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10
11
12
13
14
15
16
17
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19
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31
Month//Bulan
1
2
3
4
5
6
7
8
9
10
11
12
Year//Tahun
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
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2009
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2007
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2003
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1937
1936
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1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender // Jantina
*
Male // Lelaki
Female // Perempuan
IC Number // Kad Pengenalan
*
BruHIMS number
*
Place of stay // Tempat tinggal
*
Full Address // Alamat Penuh
City // Bandar
Postcode // Poskod
District // Daerah
*
Brunei - Muara
Tutong
Kuala Belait
Temburong
Mobile Number // Nombor Telefon
*
House number // Nombor Telefon Rumah (optional)
E-mail // E-mel (optional - untuk menerima notification)
PAYMENT METHODS // KAEDAH PEMBAYARAN
Payment method // Kaedah Pembayaran
*
Cash over Counter // Pembayaran tunai di kaunter RIPAS
Cash on Delivery // Pembayaran tunai semasa penghantaran
Bank Transfer
Delivery Method // Kaedah penghantaran
*
Standard
Express
Bank's Name // Name Bank
*
Bank's Account Number // Nombor Akaun Bank (optional)
REPRESENTATIVE DETAILS // INFORMASI WAKIL
Full Name // Nama Penuh
*
First
Last
Relationship with Applicant // Hubungan dengan pemohon
*
IC Number // No. Kad Pengenalan
*
Full Name // Nama Penuh (optional)
First
Last
Relationship with Applicant // Hubungan dengan pemohon (optional)
IC Number // No. Kad Pengenalan (optional)
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