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PERSATUAN PENDIDIKAN SAINS PERUBATAN DAN KESIHATAN MALAYSIA
(Malaysian Association of Education in the Medical and Health Sciences)
MEMBERSHIP APPLICATION FORM To: Unit Pendidikan Perubatan Fakulti Perubatan Universiti Kebangsaan Malaysia
Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur Sir/Madame I wish to become a member of the Persatuan Sains Perubatan dan Kesihatan Malaysia and I hereby agree to abide by the Bye‐Laws of the Association. Personal particulars: Full Name: ___________________________________________________________________________________ (in capital letter) Date of Birth: ____________ I.C. No/ Pasport No: _____________________________ Sex: __________________ Nationality: ______________________________ Profession: _________________________________ Job Title: _________________________________________ Address of Workplace: __________________________________________________________________________ ____________________________________________________ Tel/Fax No: ______________________________ Residential Address: ____________________________________________________________________________ ________________________________________________ Tel No: ______________________________________ Email address:_________________________________________________________________________________ Area of Interest/Expertise: _________________________________________________________________ _________________________________________________________________ I hereby forward a cheque/money order/cash of RM _______________ (payment for Entrance Fee RM20 and Annual Subscription RM 30) Date: __________________________ Signature of Applicant: _______________________________ PROPOSER Name of Proposer: _________________________________________________________
FOR OFFICE USE ONLY The Application of ______________________________________ for membership to the Association was approved at the Executive Council Meeting on __________________________________ Date: _______________________ Signature of Honorary Secretary: ______________________________