Membership Application

All information provided will be kept confidential.
Fields that are marked with * are compulsory.

Login Details

Please specify the login settings to your account.

Username*:

Password*:

Confirm Password*:

Private Question: e.g.: What is your mother's maiden name?

Answer to Question:

Account Type

Registration Information

Please your name and personal details as per your IC/Passport.

Title:

Full Name:

Email:

Confirm Email: (typo checking, don't copy-paste)

New NRIC No.: for Malaysian citizen

Citizenship & Passport No.: for non-Malaysian citizen

Mobile No:

NSR No:

Preferred Mailing Address

Home Address

Address Line1:

Address Line2:

City:

State:

Postcode:

Country:

Phone No:

Fax No:

Practice Address

Address Line1:

Address Line2:

City:

State:

Postcode:

Country:

Phone No:

Fax No:

Qualifications

You will be required to submit certified copies of certificates later.

Degree 1:

Institution:

Year:

Degree 2:

Institution:

Year:

Degree 3:

Institution:

Year:

Present Appointment:

Past Appointments

State nature of position, duration of appointment and name of institution.

Publications

Publications in peer-reviewed journals.

Referees

Please provide names and addresses of three referees (two of whom are members of the Academy and are able to confirm your standing as a practising specialist).

Name of Referee 1

Address

Name of Referee 2

Address

Name of Referee 3

Address

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Online Membership System

Login Details

Registration Information

Home Address

Practice Address

Qualifications

Past Appointments

Publications

Referees