Subscription Renewal Form

Subscription Renewal Form

Type of Member

 Ordinary Member    Life Member    Corporate Member   

From Year : (required)

Until Year : (required)

Name : (required)

NRIC No. : (required)

Member I.D. : (required)

Email Address : (required)

Contact No. : (required)

 

Payment:

To be made upon submission

 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 )

 

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File attachments:

[file_bank_in]

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Message body:

Renewal Form Submit

Type of Applicant : [type_of_applicant]

From Year : [from_year]

Until Year : [until_year]

Name : [name]

NRIC No. : [nric]

Member I.D. : [member_id]

Email Address : [correspondence_email]

Tel : [contact_no]

Payment Gateway : [payment_gateway]

Amount : RM [payment_amount]

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