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Are you a national citizen of South Africa?
Yes
No
Specify citizenship:
Full Names:
Surname:
Gender:
Male
Female
Other
Identity or Passport number:
Current Address:
Phone Number:
Email Address:
What is your marital status?
Married
Widowed
Divorced
Single
Number of Dependants:
At which university did you complete your degree?
List your degrees:
When did you complete your community service?
How many years of experience do you have as a Doctor?
In which City, Town or area were you raised in?
Are you registered with the HPCSA?
Yes
No
Are you registered with the Board of Healthcare Funders?
Yes
No
What is your MP number?
Do you have a practice number?
Yes
No
Practice number:
Employment Status:
Full-Time Employee
Self-Employed
Part-Time Employee
Unemployed
Other
Please Specify Employment:
Would you like your own private practice?
Yes
No
Maybe
In which province would you like to practice in?
Gauteng
Western-Cape
Eastern-Cape
Northern-cape
Free state
Kwazulu-Natal
Limpopo
Mpumalanga
North West
In which City, Town or Area would you like to open your own private practice?
What is your medical field(s) of interest?
Who do you currently bank with?
Do you have any debt?
Yes
No
Please specify. This will be needed for your credit application process:
Are you currently in debt review?
Yes
No
What is your entrepreneurial/business experience?
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