Malaysian Society of Anaesthesiologists - Membership Application Form

Title:

Dr. / Assoc. / Prof / Dato' / Tan Sri

Name:

NRIC (New):

NRIC (Old):

Race:

Nationality:

Sex:

Male Female

Marital Status:

Single Married Others

Work Address:

Work Town:

Work Postcode

Work State:

Work Phone:

Work Fax:

Home Address:

Home Town:

Home Postcode

Home State:

Home Phone:

Mobile Phone:

Mailing Address:

Send to: Home address Work address

Email:

Practice Type:

Government University Private

Practice Status:

Trainee Specialist

Special Interest:

Qualifications:

1.	Qualification:
	Institution:
	Year of Award:

2.	Qualification:
	Institution:
	Year of Award:

3.	Qualification:
	Institution:
	Year of Award:

Referees:
(compulsory;
Referee must
be a member
of the MSA)

1.	Referees:
	Address:
	Position:

2.	Referees:
	Address:
	Position:

3.	Referees:
	Address:
	Position:

Verification Code

IMPORTANT NOTE

This membership application will have to be accompanied by the payment of annual subscription i.e. RM75.00 for specialists (Ordinary Membership) and RM50.00 for trainees (Associate Membership). You can also opt to be a life member by donating an amount of RM1,000 to the Society.

Payment can be made in the following manner:

Via telegraphic transfer, cheque or cash payment to account:
Name: Malaysian Society of Anaesthesiologists
Name and address of bank: CIMB Bank Berhad, KL Main Branch, 11 Jalan Raja Laut, 50350 Kuala Lumpur
Account No: 80-0021098-1
Code: CIBBMYKL

Please email the bank slip to the secretariat via secretariat@msa.net.my.

Kindly note that the MSA Executive Committee will not consider your membership application if payment is not received.