Membership Application Form

Return to: Unit 1.6, Level 1, Enterprise 3B, Technology Park Malaysia, Jalan Innovasi 1, Bukit Jalil, 57000 Kuala Lumpur, Malaysia

Email: secretariat@msa.net.my http://www.msa.net.my Fax: 603-8996 4700

Membership fees:
RM 75 (ordinary member), RM 50 (associate member), RM 1,000 (life member)
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.

 

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