4th Poor, E-mail: memberships@mma.org my / query@mma ore.my ‘Application For O new Membership =O. MALAYSIAN ME ICAL ASSOCIATIO! : iattbensnariSiae i To : the Honorary ‘Secretary (Optional New | alae on semen i MMA House, 124 Jalan Pahang, $3000 Kuala Lumpur Tel No. O34041 1375 Fax No, O40 | 9929 t [MMA Website: www mma.org.my Renewal of Membership © Lapsed/Rejoined (Please tick) 1 Name CLTTT TTT rtt TI LTTTTT TTT ttt 2. Title (eg.Tan Sa, Date’ Prof, Br) COLT TTT TT rrr ttt) a nric new [TTTTTI old im 1 4 oaeoraith COLL 5 sex: Ovae © female 6 mawaistaus — Omared = Osinge — Qomess COTTE ELITE EEE EIT rr) 7 raoraity: Oraiysn — Qowweryenwey — ELE TTT EPP LE EEP rrr) 8 race; Onaly —Ocinese Oincion Oivan Ortadezan oversee CLITTIITT ILI 9. MMCRegistratin No: 10 oxeotreewenmme — C[TETETTT (teenth oe el i 1 Spouse's name [ CELLET rr rrr LI COLCLIT Tr) 2 spoussnacnew = CITT TIPTTTTIIIIT) o §=EEEETTrT 'she/she Joint Member ° 13 Professional Qualifications: (Basic Denree and One Yes No {ifjaint member, spouse must complete & submit a separate aplication frm) Postrraduate qualification) (Pot ley ei eo comptes on dnt aig ate) TUATERATION DEGRE ‘BATE OF GUATFREATION. basic DEGREE fPOSTGRADUATE POSTGRADUATE fs POSTGRADUATE 14 Working Address, [TTT TETETITI LITT TT LITLE) Pox codef TT TET) LTTITTTiT tt ttt LITTTITTT Itt tit) CLOUT LET TTT LITT ttt tt) city LUT TT Jove TTT TTT TTT Jeounty LITTITTTt tT) aswomenddress LT TT TTT LITT TET TET TTT TTY) Po cone Tt LITT TTiT TT rt tri iit ttt iit iti itt CLE TTTTT Trt rrr rrr iri tt TITTTT ety (TTT TOT state TTT ETT country [ TTTTT 16 Contact No HSE )- COLT TLE) [ LITT) HP -CT jrax [ [TTT ema [TT TTT [TTT TTT TT TTTTTiT Tt rr ryt 17 Please send my corcespandence to my {Please inform change of address, telephone num 18 Please tick V the appropriate box Employment Status D(A) Armed Forces 1 (as) Armed Forces (6) Government (65) Government DP) Pavte Dis) Private DU) Universiy Bus) Universiy Gi (Ms) Medical student working Address O tHouse address rs e-mail address whenever you have moved for both the working & house address) Categories Medical officer House Officer Registrar Specialist Specialist Public Health Specialist General Practitioner Private Medical Officer Specialist Lecturer oooooooo19 Your Nature of Practice : [Pease tick (v) your specialty below) Descrition Accident & emersency Forensic Medicine Neuro Surzery Psvenatry Braesinenes Goveenmant Medical Ofioe Nuclear Medicine Pb Health Auiaten Medicine SGostraenterelory Obstetric & Gynaceolony Radiolory Carditony {General Mesieine/Intemal Medicine (eeupstional Health Radietheraoy Gerditoracic Surmery (General Practice Oncolons Retabitation Medicine Ghemealathoions General Suraery Ophenalmolony surgery Renal ediane Chest Meare General Patholony Onhopaede surzery pets Colorectal & Gen Surgery Hoematolony Oterninatsrmgotery reumatology Chik Psychiat Heeatolony Prvate Hospital Medical Offcer Sports Medicme Cytonathotomy Histapatholony Paedittes Thorac Medene Dermatolon tmmunotoay PaediateeSurnery Society Poverty Dentist Industral Heaith Paedatee Gastroentloay Underwater Medicine Endocrimoogy Medica Adminstration Parastolons UrosoreSurzery Ear, Nose Throat Surgery Merobilony Physiean & Rheumatolonist Fy ga ies Facial Surm Nephrol Fy Biol cre ence Others Please State) Famly/bimary Care Physician Neuron Paste Srmery TAM SUBMITTING THIS MEMBERSHIP FORM AS BELOW (Refer tothe sttached page for subscription Fees Rate) © ordinary Menber loinc Oxinary Mernber(Spous)—Ooiate ember QOverease Oudmary Member O)feMember © doit ue tame (Spouse} > Qoute Doctor (rovsnay repre wh the MMC) ‘Medical Officer (All doctor forthe fist ten (10) years after houtemanship; (Please tik Vapproprite box) Cohen Ese fatty singe ome Corny Came Conve Chto nye © medal sudenerber rave stateyerofstdy [TTP] unser vevratconsieton CIT {aleve of ereaton fo te respecive Univers /Coeqe rua student meres Insubmiting an application for membership ofthe Malaysian Medial Assocation, lapreeto abe by the Consttion ofthe Assocation & ‘eguation 5 may be enacted from time to time, Stature of Application Signature of Proposer Signature of Saconder ame Name Name bate ic No Nie No [PLEASE NOTE THAT THE PROPOSER AND SECONDER MUST BE MEMBERS OF NMA) [NOTES : PLEASE ENSURE THAT THE APPLICATION FORM Is FULLY COMPLETED AND ACCOMPANIED BY THE FOLLOWING DOCUEMENTS TO AVOIO DELAY IN PROCESSING YOUR APPLICATION 1 Copy ot ristration wth Malaysian Metical Council OR Copy of current Aa ‘of Department for government doctors 2 Copy of identity card or passport 3. Acopy of your photograph V/C size tobe attached nthe space provided (Optional) {4A Crossed Cheque / Bank raft / Money Orcer OR postal ore forthe appropriate amount to be payable to’ MALAYSIAN MEDICAL ASSOCIATION’ On complete the avachment eri card form. {the membership follows the calender yer Le. \tcommenceson Ist January and ends on 31st December of each year. Therfire, itis advisable to join early inthe year to enjoy the whole year benefits) 1 Praticng Cetsicate OR A leter of Certieation from the Head SUA DAPATKAN PENGESARAN PERKHIDMATAN DARIPADA KETUA JABATAN SERIRANYA TIDAK MELAMPIRKAN SUIL PERAKUAN AMALAN TAHUNAN (APC) 'ATAUSIIL PENDAFTARAN DENGAN MAJLIS PERUBATAN MALAYSIA ‘saya dengan inl mengesananbahawa Or evmennn NO. KIP BaP a 1 10. 1/P tama. Sedang berkhideat ei Hosptal in sebagai * House Doctor atau * Pegawai Perubatan di tahun. Sekin trina fash ‘Tandatangan Name vee ne cop NOKIP at wen - - Toth oe To Publication Section, Mma (for doctors ony) rm intrested)/nt interested in receiving a copy ofthe MIM. Ors On rice use ony Taye Tor Caregen WOO cu TecapEN Ta al Ee by Comments anys wenn cn pate Time - venARTICLE III MEMBERSHIP The memshership othe Associaton shall consist ofthe Following estegoice:= (1) Honorary Membership: "he Associaton may confer Honceary Mersbership on those persons who, whether or not registered inthe Medial Register. have done exesptional work inthe fields oF Medicine and ald sienees or have rendered meritorious service in the cause of Mesicine associated sciences ot his Assovaton, Life Membership ofthe Association shall be opened fo Ordinary Members sho in place of annual subscription tothe Associaton, shall have contributed to the Capital of the MMA Special Savings {Life Investment) Fund established by the Association. an amount determined by the Anoual General Meeting from tine to time. The annual income. generated by investment ofthe ‘Accurulaed Capital contributions of each member tothe Fund shall be irevocably assigned in perpetuity by the contriotor to the ‘Counc the ASsoetaten to disburse as it deems fi (3) Ordinary Membership: Ontinary Membership shall be opened 10 every medieal prttioner whether repistered ur provisionally reistned wr cna ‘epstre inthe Register kept by the Registrar of Medical Practitioners and those terms shall have the meaning assigned othe hy the Medieal Repistation Ordinance curenty infarc. (4) Overseas Membership: ‘Oxcrncas Membership shall be opened to a registered medical practitioner whose permanent residenes is outside Malaysia, 8) Associate Membership Assceiate Membership shall be opened w para Medical Personnel who being qui in dir respective profession Iezlly ative in Malaysia, (6) Student Membership: ‘Suuent Meinhership shall be pened to registered medial stodents who ae eiizens of Malaysia and who ars undergraduates i ‘ny mica school provided thal local Universcy of University College student shall be admitted as a member without the ror writen approval ofthe Vice-Chancellor concerned (7) Exempt Members! Esempt Membership shall be opened to medical practitioners wh have boon Oedinary Members in goo sanding af at least 20 years a have attained the age oF 65 years. ARTICLE IV SUBSCRIPTIONS (1) The Annost General Mecting on the recommendation of Council shall determine fom time to tne the rate of saul subscriptions payable by al categories of members extent Honorary Members sujoat a the rior approval ofthe Registrar ef Soieties (2) Ihe subscriptions shall come due and payable on Ist January of each year without any noice trom the Associaton and shal These an tndischarged debt duc tothe Association on the 30th June ofthe same year (3) tFany momibe shall ail to pay subscription for any year and this flue shall continwe to persist on the 30th June of that ye, th saber shall ave to enjoy all the bones and privileges available to or enjoyed by members in bencft immediately (and ‘hall ot be eligible o ater oe vole at any general meeting of Ge Assocation) and if such member sbal! (6) contin to fal wo stile the subscription in arrears for that year when it fell ue and the subscription in arears remain foutstanding on the 31st of December that year heshe shall suomatically cease to be @ member of the Association SUBJECT TO ARTICLE VID or tle the sulseription én areas for that year when i fll due before the 31” December that year all betes tmivilegs sssilable to or enjayed by members in benefit shall be immediately restore al for avoidance a doubt, in Stich an event, the period ofthe membership of sueh member sill not be taken to have been broken by vite of the cession of hivher membership privet bse settlement of the subscription in arrears within that same year when it fell ce. ai (4) A member in bent isa member eho isnot in arears of subseripions for more than 6 mothsARTICL PRIVILEGE OF MEMBERSHIP. (1) The prvllege oF membership is the partieipasen in all acti Jor organized hy the Association inching 4 the Council adits com (6) the Branch and its Sub-en lly Seotians, Societies ais Sub-commitees: inthe eantext ofthe abjees ofthe Assosiaton, fal and adeyuate note being given in each member wal yc atts, (2) Honrary, Associate. Suudem and Overseas member will enjoy all he privikages of Ordinary ite and Exe ‘escept hat of voting 0 wr holding office inthe Conseil andl Braach Co plinerabership (6) All members ofthe Council and officers ofthe Association inc Represenatves so Government und Non-Governmental Organisations shall be Malaysian citizens ARTICL vi ‘TERMINATION OF MEMBERSHIP (1) Termination of membership shal tke place in ony one mare ofthe Following ways (3) By clear intention expressed in writing to resign membership for whatever ease, ) Automatically on the 34st Decemer othe ye when the annual membership subscription alsin arrears foe more than 12 months. (Gi) Automatically 2 Counc dloy the name wf the members removed rn the Medical Register maintained by the Malaysian Mesical av) By expulsion by the Association ating in ascordance with the procedure preseribed by the Code of ties and Rules ofthe Ethics ‘Comite prescribed by the Assieiation and binding on all members, BY-LAW IIL SUBSCRIPTIONS (2) The rate of annual subscriptions payable by each category of memhersip shall be (6) Oalinary Members Joint Ordinary member (Spouse) RM 250,00 per stam RMI25- (Total RM375.09 per ansum) ‘ij Overseas Members RM 500.00 per annom i) Associate Members RM 250.00 per annum {v9 Stet Members RM 2000 per sour @) REDUCTION OF SUBSCRIPTIONS "Nhe Council may reduee annua! subscriptions for members as tllows: 42) RM 150,00 for all registered Medi (0) Deleted 4) New members ia ay category of membership speed in By-Law 1 (1) (except sent members) cml in 1 Flat December. the membership fee is waived. The membership fee aid sold be fr the Tolesing sexe Putters inthe fst 10 ears of practice period (4) RM 112.50. (om 121408) and RM 125.00 (rom 1/0) for Now Members in any eategery of membership specie in By Law II (1] (except student members) enrolled in the period I July to 31 December. the reduction being for the year onlyMALAYSIAN MEDICAL ASSOCIATION 4th Floor, MMA House, 124 Jalan Pahang, 53000 Kuala Lumpur Tel No, 03-4041 1375 Fax No. 03-4041 9929 E-mail: memberships@mma.org.my / query@mma.org.my MMA Website: www.mma.org.my CREDIT CARD PAYMENT INSTRUCTION FORM (PIF) "hereby ashore (ame of bank to debit my acount Please tick theretrantbox — []Mosercert or [isa card forthe payment ot subscription els asindatesintheatached form [7] vamembershipnenewaton [apse & ejined membershie ite membersio [ventas tembershin Life Membership MMA Membership Subscription fee for year Total DETAILS OF CARDHOLDER Cardholder's name (as stated in the credit card) Full Name. VCNo New or Address : Poscode E-mail Office Tel No He Card Expiry Date Code No: Master/Visa credit card account no | agree to the terms and conditions of the platinum/gold/classic cardholder agreement which have been made available tome. Cardholder's signature Date FOR OFFICE USE ONLY Merchant number Authorisation code Authorisation date : Verified by (name of staff) Signature Date