Membership Form

Membership Signup

I hereby apply to be a Member of the Malaysian Association for the Advancement of Functional and Interdisciplinary Medicine and shall abide by its Rules and Regulations.

I also remit my first Annual Dues. ( Please forward your banking slip to whatsapp **** or email *****)

Email Address *

Name as in NRIC/Passport *

Full Name as in NRIC/Passport

Title

Dr. Mr, Mrs. etc

Designation / Vocation *

Residential Address *

Postcode

City

Mailing Address *

Postcode *

City *

Telefon (H) *

Telefon (O) *

Mobile Phone *

Fax *

Qualifications

University

Office Address *

Postcode *

City *

Payment Slip

Drag and drop files here or Browse

Please choose your payment slip pic and submit to us.

reCAPTCHA *

Phone