MALAYSIAN MEDICAL COUNCIL APPLICATION
FOR COPY OF CERTIFICATES AND OTHER
SERVICES
1. Personal Information
Full Name of Applicant : FARAH ILYANI BINTI ROSLAN
(as per NRIC/Passport)
NRIC/Passport No.*: 980910-07-6108 Citizenship: CITIZEN
MMC Provisional/Full Registration No.*: Latest TPC/APC No.*:
Residential Address 20 LORONG SERI INDAH 5, TAMAN SERI INDAH, 13200 KEPALA BATAS, PULAU PINANG
Postal Address 20 LORONG SERI INDAH 5, TAMAN SERI INDAH, 13200 KEPALA BATAS, PULAU PINANG
Tel (office): Tel (mobile): 019-6236945 Email: fararsln@[Link]
*Strike out whichever is not applicable
2. Application (Please tick (√)) - For service rates, please refer to the MMC’s Fee Rate for Services Rendered at [Link]
Search & verification of information (per verification) (RM75) Copy of Record of Proceedings (RM50)
Request for documents to be sent through fax (RM5) Copy of certificate (per certificate) (RM200)
Rechecking of EPR examination results (RM300) Request for documents to be sent by Registered Post
(Date of exam): or Poslaju – in Malaysia (RM20)
Amendment/Addition of information on documents/
certificates (RM50)
Others: (Please specify requirement, subject to availability of service)
3. Application Details (Please specify document/certificate needed with dates and other relevant information)
APPLY FOR A DATE AMENDMENT IN 'QUALIFICATION' SECTION
DATE OF PASSED EXAM : FROM 19/02/2023 TO 09/02/2023
DATE OF AWARDED QUALIFICATION : FROM 20/06/2023 TO 19/02/2023
Note: Please use a separate sheet of paper if space is inadequate.
4. Payment Details KUMPULAN WANG MAJLIS PERUBATAN MALAYSIA
CIMB Islamic Bank Berhad
Account Number: 8600098716
Payment details (online banking / debit card / credit card )*: ONLINE BANKING Date: 09/08/2023
Sum: RM 50
Proof of payment / Transaction ID (if applicable):
*Strike out whichever is not applicable
5. Mode of collection (Please tick (√)) By Hand By Post On Behalf**
** For collections on behalf, please bring along an authorization
letter from the applicant on the day of collection.
09/08/2023
Date
For Official Use:
1. Application: 2. Comments/Instructions:
Approved/Not Approved*
(*Strike out whichever is not applicable)
Date Rubber Stamp & Signature of Approving Officer