Registration Form

Type of Applicant

 Ordinary Member    Life Member    Corporate Member    Affiliate Member    Associate Member    Fellow of AIMM    Friends of AIMM   

 

Personal Particulars

Title :  Dr    Prof    Mr    Miss    Mdm   

Sex :  Male    Female   

Personal Photo ( Passport size ) ( max. file size limit to 2MB & only allow format pdf, docx, txt, csv, jpg, png and gif ) :

Name : (required)

NRIC No. : (required)

Date of birth ( YYYY-MM-DD ) : (required)

Nationality :

Name of Clinic, Company or Centre Representing ( if applicable ) :

Correspondence address :

Address Line 1 : (required)

Address Line 2 :

City : (required)

State : (required)

Postcode : (required)

Country : (required)

Tel : (required)

Fax :

Handphone :

Email Address : (required)

Website :

Home Address ( optional ) :

Address Line 1 :

Address Line 2 :

City :

State :

Postcode :

Country :

 

Professional Qualifications

( Please state Degrees / Diplomas, Year of Graduation / name and country of Institutions. Photocopies of documents to be submitted with the application of membership by fax or scan and send through the browse documents as required below. )

1) Degree / Diploma :

Year of Graduation :

Name of Institution :

Country :

1) Browse documents : ( max. file size limited to 2MB & will only allow pdf, docx, txt, csv, jpg, png and gif formats )

 

2) Degree / Diploma :

Year of Graduation :

Name of Institution :

Country :

2) Browse documents : ( max. file size limit to 2MB & only allow format pdf, docx, txt, csv, jpg, png and gif )

 

3) Degree / Diploma :

Year of Graduation :

Name of Institution :

Country :

3) Browse documents : ( max. file size limit to 2MB & only allow format pdf, docx, txt, csv, jpg, png and gif )

 

4) Degree / Diploma :

Year of Graduation :

Name of Institution :

Country :

4) Browse documents : ( max. file size limit to 2MB & only allow format pdf, docx, txt, csv, jpg, png and gif )

 

5) Degree / Diploma :

Year of Graduation :

Name of Institution :

Country :

5) Browse documents : ( max. file size limit to 2MB & only allow format pdf, docx, txt, csv, jpg, png and gif )

 

6) Degree / Diploma :

Year of Graduation :

Name of Institution :

Country :

6) Browse documents : ( max. file size limit to 2MB & only allow format pdf, docx, txt, csv, jpg, png and gif )

 

7) Degree / Diploma :

Year of Graduation :

Name of Institution :

Country :

7) Browse documents : ( max. file size limit to 2MB & only allow format pdf, docx, txt, csv, jpg, png and gif )

 

8) Degree / Diploma :

Year of Graduation :

Name of Institution :

Country :

8) Browse documents : ( max. file size limit to 2MB & only allow format pdf, docx, txt, csv, jpg, png and gif )

 

If applicable :

A. Malaysian Medical Council (MMC) Full Registration No. :

MMC Annual Practising Certificate No. :

B. Name of Complementary Medicine Society within FCNMAM :

Membership Grade and No. :

C. Name of other profesional bodies in which you are a Member :

 

Complementary Modalities approved by The Ministry of Health, T&CM Division

Please tick modalities practised by you / in your Clinic, Company or Centre.

 Postgraduate Level   

 Degree / Diploma Level   

 Diploma / Certificate   

 Nutritional Medicine   

 Hypnotherapy   

 Psychotherapy   

 Chiropractic   

 Osteopathy   

 Herbal Medicine   

 Natural Medicine   

 Music Therapy   

 Reflexology   

 Aromatherapy   

 Reiki   

 Crystal Healing   

 Blind Massage Therapy   

 Soft Tissue Manipulative Therapy   

 

Your other Specialty Procedures / Therapies

A.
B.
C.
D.

 

Public Information

( Please tick accordingly )
I hereby  authorize    do not authorize    AIMM to disclose any personal / company information or any particulars, professional qualifications, place of practice
( excluding payment information, home address, I.C. No., ... or )

that is mentioned in this Application Form for listing / disclosure in AIMM Publications, Website, Facebook or other public electronic / internet media.

 

Payment of Membership:

To be made upon submission of this application

 By Cheque Deposit    By Interbank Online Transfer   

Name of Account Holder : Persatuan Perubatan Integratif Malaysia

Name of Bank : Alliance Bank Malaysia Berhad

Bank Account No. : 141760010054697

Bank SWIFT Code : MFBBMYKL

Amount : RM

Please email Cheque Deposit Slip to info@integrativemedicinemalaysia.org or by fax.

Browse scanned cheque / bank in slip : ( max. file size limit to 2MB & only allow format pdf, docx, txt, csv, jpg, png and gif )

 

Name of Proposer:

Name of Seconder:

( Proposer and Seconder must be existing Ordinary Members )