ACADEMY OF MEDICINE OF MALAYSIA
No 19 Jalan Folly Barat, Off Jalan Ledang
50480 Kuala Lumpur

NOMINATION FOR FELLOWSHIP

Please print (A4 portrait) & complete this form and mail, together with attachments to the address above. You may also wish to download this form in Word DOC format here. (290KB)
Name:
Qualifications:
Date of admission as a Member of the Academy:
Address:
Current position:
Working experience and previous posts held: (with dates - starting from current post)
Positions held in professional societies (with dates):
Other contributions to advancement of specialty:
Publication in peer reviewed journals. No. _______________ (Please attach list):

 

Signature of Applicant/Academician
We certify that the applicant has been a member of good standing and we believe that he/she has satisfied the minimum criteria for conferment of Fellowship of the Academy of Medicine of Malaysia. (F.A.M.M.)

Proposer:

 Name
Signature
Academy Member since

 

Seconderr:

 Name
Signature
Academy Member since

 
       Signed on this __________ day of ___________ (month), ___________ (year)

REMINDER: Please submit a complete C.V. with this application.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOR COLLEGE'S USE ONLY

We, the College of the Academy known as _________________________ certify that we have examined this nominee's credentials and find that he/she satisfies the agreed minimum criteria and consequently to be considered by the Board of Censors.

 

 

[President]

[Hon secretary]

 

 

 

 

FOR USE OF CENSORS ONLY

The nominee has satisfied/not satisfied the criteria for conferment of fellowship.

If not satisfied criteria, reasons:


 
The nominee is recommended/not recommended for conferment of fellowship.
Signed

[Chief Censor]