Online Membership Application

1. REGISTRATION INFORMATION

(WRITTEN IN CAPITAL LETTERS) (Please fill in every detail)

FIRST NAME *

MIDDLE NAME

SURNAME *

I.C. / PASSPORT NO *

MAILING ADDRESS *

POST CODE *

CITY *

STATE *

COUNTRY *

CONTACT NO *

+1

HANDPHONE *

+1

EMAIL *

2. SAHAMM MEMBERSHIP (PLEASE CHOOSE ONE)

PLEASE CHOOSE ONE.

I WOULD LIKE TO JOIN / RENEW MY SAHAMM MEMBERSHIP FOR THE YEAR (Applies to only Corporate Membership) *

PLEASE CHOOSE YOUR MEMBERSHIP TYPE *

GRADUATING YEAR (ONLY FOR STUDENT MEMBERSHIP (Medical Students) )

3. SUPPORTING DOCUMENT

(REQUIRED BEFORE FINAL APPROVAL BY THE EXCO, PLEASE ENCLOSE A COPY WITH THIS FORM)

o COPY OF CURRENT MEDICAL LICENSE & CURRENT YEAR PRACTICING CERTIFICATE (For Doctors)

o COPY OF STUDENT’S ID CARD (For Medical Students Only)

PLEASE UPLOAD YOUR SUPPORTING DOCUMENSTS HERE (CURRENT MEDICAL LICENSE & CURRENT YEAR PRACTICING CERTIFICATE or STUDENT'S ID CARD) *

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4. MEMBERSHIP IN OTHER ASSOCIATION

ARE YOU A MEMBER OF ANY OTHER SOCIETIES (IF ANY)? *

IF YES, PLEASE PROVIDE THE NAME OF THE ASSOCIATION NAME

5. HOW DID YOU HEAR ABOUT SAHAMM?

HOW DID YOU HEAR ABOUT SAHAMM?

6. MEMBERSHIP FEE

Note: For Corporate Membership, a one-time sign-up fee (Membership fee) and the 1st year Annual fee will be required upon sign-up. All fees paid are non-refundable.

7. PAYMENT METHOD

i) MALAYSIANS: Online Transfer or by Cash / Cheque Deposit

ii) FOREIGNERS: Telegraphic Transfer or PayPal

BANK DETAILS:

Beneficiary Name: SAHAMM

Bank: Public Bank Berhad

Account No: 3-166-497-325

Swift Code: PBBEMYKL

Address: Mont Kiara Branch,
1 & 3, Jalan Solaris 1,
Solaris Mont Kiara,
50480 Kuala Lumpur, Malaysia

Please upload your payment slip here

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8. HONOR/ATTESTATION STATEMENT

TO THE BEST OF MY KNOWLEDGE, THE INFORMATION IN THIS APPLICATION IS TRUE, COMPLETE, AND CORRECT, AND IT IS PROVIDED IN GOOD FAITH. I UNDERSTAND THAT THE INFORMATION PROVIDED IS SUBJECT TO EXCO COMMITTEE’S APPROVAL AND AUDIT.

Signature *

Date / Time *