Please enable JavaScript in your browser to complete this form.Organisation Name *Total Staff Strength *Company AddressFacilitator's Name *FirstLastFacilitator's Contact No (Office or Handphone)Facilitator's Email Address *Additional Authorised Personnel's DetailsScreening Details Handphone) Facilitator's Staff Mode of Appointment Booking *Online Self-Booking by StaffBulk Scheduling by HRStart Date *dd-mm-yyyyEnd Date *dd-mm-yyyyRequired ServicesTypes of Medical Screening and Employment Screening *Work Permit & Work Permit Renewal 6ME6MEWork Passes Medical ExaminationRefer to Special RequestsPost-Screenings Reports ArrangementIndividual ReportsIndividual Report Mode of Dessemination *[MOM Portal-Submission] within 2 working days[Non-MOM Portal Submission] emailed to company within 2 working daysNon-Standard Employment Screening reports emailed to company within 3 working daysRefer to special requests.Billing Arrangement *Billable to companyPayable by staffBilling Terms *Monthly softcopy invoice with attendance listQuarterly softcopy invoice with attendance listRefer to RequestsSpecial Requests/Things to NoteTo state here for any requests not stated in this formProject ManagementSales Account Manager *I would like to request for oneI am already liaising with Minmed Sales Representative.Sales Account Rep EmailSubmit
