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SABAH
MEDICAL ASSOCIATION (SAMA) MEMBERSHIP APPLICATION FORM
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To:
Honorary General Secretary
Sabah Medical Association
P.O.Box 11827
88820 Kota Kinabalu
Sabah, Malaysia |
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Name |
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Title |
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NRIC |
(new) |
(old) |
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Date
of Birth |
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Age |
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Marital
status |
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Nationality |
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Date
of first arrival in Sabah: |
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Professional
qualification(s) |
University/Institution |
Country |
Date
of qualification |
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MMC
Registration No |
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Employment
status (e.g., HO, Govt MO, Govt Specialist, Private MO, GP, Private
Specialist) |
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Nature
of Practice/ Specialty |
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Residential
address |
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Telephone
no: |
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Office
address |
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Telephone
no: |
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Postal/Correspondence
address |
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Telephone
no: |
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Handphone
no |
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E-mail
address |
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We
strongly urge you to provide an e-mail address for effective, speedy
communication in the future
(Page
1of 2)
Please attach your remittance here
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I
am submitting this membership application to become: (please tick) |
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Ordinary
Member (subscription RM$60.00 per annum) |
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Associate
Member (subscription RM$30.00 per annum) |
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Life
Member (subscription RM$300.00) |
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Please
submit your remittance together with this application. Cheque
to be payable to Sabah Medical Association |
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In
submitting an application for Membership of Sabah Medical Association, I
agree to abide by the constitution of the Association and regulations as
may be enacted from time to time. |
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Signature
Date
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(Name:
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Proposer
(name):
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Signature:
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Date:
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Seconder
(name):
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Signature:
.. |
Date:
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(Please
note that the proposer and seconder must be members of SAMA)
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Date application received: |
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Payment Amount:
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(Cash/Cheque/MO/PO):
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(Cheque/MO/PO No.):
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Receipt issued by:
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(Signature):
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(Receipt No.):
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Approved by Council on:
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Entered into computer on:
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Membership No issued:
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