Registration Form Form to register new members Type of Application Ordinary Member Life Member Corporate Member Affiliate Member Associate Member Fellow of AIMM (by conferment) Personal ParticularsTitle :(Required) Dr Prof Mr Miss Mdm Sex :(Required) Male Female Personal Photo ( Passport size ) ( max. file size limit to 2MB & only allow format pdf, docx, txt, csv, jpg, png and gif ) :Max. file size: 2 MB.Name :(Required) NRIC No. / Pasport :(Required) Date of birth(Required) DD dash MM dash YYYY Nationality :(Required) Occupation(Required) Name of Clinic, Company or Centre Representing ( if applicable ) : Corresponding Address or Place of Work:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Address Corresponding Address Place of Work Tel :Handphone :Email Address : Website : 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. )Professional QualificationsDegree / Diploma :Year of Graduation :Name of Institution :Country : Add RemoveDocument upload (Certificate upload) Drop files here or Select files Max. file size: 2 MB. 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. Nutritional Medicine Chiropractic Natural Medicine Aromatherapy Blind Massage Therapy Hypnotherapy Osteopathy Music Therapy Reiki Soft Tissue Manipulative Therapy Psychotherapy Herbal Medicine Reflexology Crystal Healing Your other Specialty Procedures / Therapies Add RemovePublic InformationAIMM to disclose any personal / company information or any particulars, professional qualifications, place of practice ( excluding payment information, home address, I.C. No., ... or ) Authorize Do not authorize Payment of Membership: Account Details Account Details 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.Bank in slip :Max. file size: 2 MB.Name of Proposer: Name of Seconder: ( Proposer and Seconder must be existing Ordinary Members )
