Rural Other Medical Practitioners (Romps) Programme Registration Form - Australian Department Of Health Page 3

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Rural Other Medical Practitioners (ROMPS) Programme Registration Form
Additional practice location
Provider Number:
RRMA:
Practice Name:
Suite:
Level:
Building:
Street Number:
Street Name:
Locality/Town:
Postcode:
Please attach a sheet containing additional practice locations if applicable (use above format).
4. Mailing Address
Practice Name:
Suite:
Level:
Building:
PO Box:
Street Number:
Street Name:
Locality/Town:
Postcode:
5. Contact Details
Daytime Contact Number:
E-mail Address:
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