International Academy of Pathology (Malaysian division) Registration Form
First/Given Name *
Last/Family Name: *
Title *
Home Address *
Identity card/Passport number *
Date of birth *
MM
/
DD
Place of birth *
Employer's name *
Employer's address *
Nationality *
Telephone no. (work) *
Telephone no (mobile) *
Email address *
Alternate email address
Pathology experience (Years) *
MEMBERSHIP FEE
Please tick the boxes below. There is a one-time registration fee of RM50 applicable to all new registrants regardless of type of membership.
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 secretariat; 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.
I enclose my *
Please choose one of the fee below. One time registration fee (RM50) is applicable to all new registrants.
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