Panel Application Form

Panel Application Form
Company Main Details
Company Name
Company Registration No
No. of Staff
Type of Industry
Establish Year
Bussiness Registration Number (BRN)
Tax Identification Number (TIN)
Company Contact Details
CEO/Manager
Address
Tel. No
Fax No.
E-mail
Applicant Details/ Person Contact

*Please key in details of your company's representative for us to contact for verification & follow up purpose.

Note

*The after-hour consultation fee (11.00 PM - 8.00 AM) for Poliklinik Ar Razi 24 Jam (Bandar Putra) is RM50.00.
All the medical bill will be paid via:

IBGCash - pelase provide us with transaction receipt as proof of payment.Cheque - physical cheque must be sent to our company by postal.
All cheques, transaction receipts and payment vouchers must be sent to us by email / postal / fax to:

Poliklinik Ar Razi, Perubatan & X-Ray

No. 16 & 18, Jalan Putra Square 1,

Malay Town, 25200 Kuantan, Pahang.

Tel: 09-517 3477 Fax: 09-517 2447 Email:accarrazi@gmail.com
Effective Date

DayMonthYear
I/We hereby agree to the terms and conditions mentioned in this letter. We shall pay all medical bills within 30 days from the date of receipt of the invoice. Either party may terminate by giving 14 days written notice to the other party, and in such of event the outstanding bills shall be settled within 7 days from the date of such termination.
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Company Main Details