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DCC Registration Form
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Registration Application Form For Foreigner
Section 1-2
Section 3
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Section 5
Section 6
Section 7
Section 8
Section 9
Section 10
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Username
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Value required.
Minimum 4 characters
Please input text in latin
Password
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Value required.
Minimum password is 8 characters
Registration Application Form
Note:
Minimum 5 years working experience relate to your health profession degree(last 5 years)
I apply for a registration at national office of Dental Council of Cambodia:
At (city / province name):
*
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For one year registration only
For registration starting from date
From date:
*
Month
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To Date:
*
Month
{{m}}
Section 1:
I APPLY FOR REGISTRATION WITH DENTAL COUNCIL OF CAMBODIA AS A
Dentist
Dental specialist
My specialty is
Other
Purpose of Registration
Volunteer
Work
Lecture
Section 2: Personal Information
Name
Family Name
*
Value required.
First name
*
Value required.
Middle name
Previous /maiden name
Gender
*
Value required.
Male
Female
Date of Birth
*
Value required.
Day
{{d}}
Month
{{m}}
PLACE OF BIRTH
Country
*
Value required.
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OK
State/province
*
Value required.
{{$select.selected.label ? $select.selected.label : $select.search}}
OK
City
{{$select.selected.label ? $select.selected.label : $select.search}}
OK
District/suburb
{{$select.selected.label ? $select.selected.label : $select.search}}
OK
Nationality
*
Value required.
Language
English
Other
If other specify your language
Value required.
CURRENT HOME ADDRESS IN YOUR COUNTRY OF RESIDENCE
Country
*
Value required.
{{$select.selected.label ? $select.selected.label : $select.search}}
OK
State/province
*
Value required.
{{$select.selected.label ? $select.selected.label : $select.search}}
OK
City
{{$select.selected.label ? $select.selected.label : $select.search}}
OK
District/Suburb
{{$select.selected.label ? $select.selected.label : $select.search}}
OK
Street#
House#
Telephone number
*
Value required.
E-mail address
*
Value required.
Please Enter Valid Email
CURRENT HOME ADDRESS IN CAMBODIA
Country
*
Value required.
{{$select.selected.label ? $select.selected.label : $select.search}}
OK
State/province
*
Value required.
{{$select.selected.label ? $select.selected.label : $select.search}}
OK
City
{{$select.selected.label ? $select.selected.label : $select.search}}
OK
District/Suburb
{{$select.selected.label ? $select.selected.label : $select.search}}
OK
Street#
House#
Telephone number
*
Value required.
Invalid phone number
+855
E-mail address
*
Value required.
Please Enter Valid Email
