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Download Membership Application Form

I hereby apply for membership as:
Title:
Name:
Specialty:
Qualification:
Place of Practice:
Postal Address:
Postcode:
State:
Tel No:
Fax No:
Mobile No:
E-mail:
Referee 1:
Email:
Referee 2:
Email:

*Ordinary Member (Entrance Fee RM 100 + RM 50 Subscription Fee)

*Life Member (Entrance Fee RM 1000 One-time payment)

*Associate (Entrance Fee RM 100 + RM 50 Subscription Fee)

Attached is a scanned copy of the proof of payment: (Image or pdf file - limit to max 2 MB file size)