IAPMD MEMBERSHIP SUBSCRIPTION & RENEWAL FORM

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YEAR OF RENEWAL *

NAME *

IDENTITY CARD/PASSPORT NO *

CURRENT WORKING ADDRESS *

PHONE NUMBER

MEMBERSHIP

Please tick one of the boxes below. Payment can be made by: 1. Banking in/transfer to a Maybank Ac no: 553131004310, registered under "PER AKADEMI PATOLOGI A'BANGSA M'SIA". Please email the receipt of the payment to IAPMD seceretariat; iapmdmembership@gmail.com OR 2. By cheque:Please make the cheque to: "PER AKADEMI PATOLOGI A'BANGSA M'SIA" and kindly email your evidence of payment.

Annual membership renewal fee *

Renewal of annual ordinary membership (RM100)

Renewal of allied membership fee (RM300)

Convert to life membership (RM1000) [for ordinary members only]

Renewal of trainee membership (RM75)

Other:

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