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

APPLICATION FOR MEMBERSHIP

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. (300KB)

 

Applications must be filled out on the prescribed forms and signed by the applicant and must be accompanied by
- certified true copies of
   a. basic medical degree(s)
   b. postgraduate qualification(s)
- List of Publications
- Reprint/copy of most significant publication
- Cheque/banker's order for RM650/- being the entrance fee (RM500/-) and first year annual subscription (RM150/-)

Ordinary Membership
Fully registered medical or dental practitioners who

Notwithstanding the criteria above, the Council may admit

Associate Membership
Medical or dental practitioners who do not fulfill the Ordinary membership criteria of the Academy.
Persons in allied professions involved in medical research who are able to further the interest of the Academy.

Candidate Membership
Fully registered medical or dental practitioners who

Members may retain their membership for a period not exceeding six years.

 

 

 

 

1. Name in Full (In Block letters):
2. Home Address:
Tel No:
 Handphone no:
3. Office Address:
Tel No:
 Fax No:
 E-mail:
4. Date of Birth:
5. IC No (Malaysian citizen)
   Citizen and Passport No (Non-Malaysian citizen)
6. Category of membership applied for (please tick appropriate box) :

          Ordinary      Associate      Candidate
7. Qualifications (please enclose certified true copies of certificates) :

  Degree/Diploma

  Institution

 Year
8. Present Appointment :
9. Past Appointments since date of basic degree (please state nature of position, duration of appointment and name of institution/place of practice)

Appointment

Date

Institution/Place of Practice







10. Publications in peer-reviewed journals (please provide photocopies of complete published articles)


APPLICATION FOR INCLUSION IN THE ACADEMY OF MEDICINE SPECIALIST REGISTER
Prospective members who wish to be included in the Academy of Medicine Specialist Register are requested to provide the following details
1. Discipline (eg Internal Medicine, Surgery, Pathology, etc)
2. Specialty (please refer to the list of specialties currently applicable in the Academy Specialist Register at http://www.acadmed.org.my)
3. Please provide details of training and practice in discipline/specialty (Include training position, duration of training and practice, institute and name of consultant/supervisor.   Enclose where appropriate testimonials, letters and other documents to support periods of training or practice)

Nature of Training

Date

Institute & Consultant/Supervisor
4. Please provide names and addresses of three referees (two of whom are members of the Academy and are able to confirm your standing as a practising specialist)
Name:
Address:
Name:
Address:
 

Name:
Address:

 

 
 

Date:

  

Signature:

 

 

OFFICE USE ONLY

 

Verified by Board of Censors

on

Chief Censor

Approved

on (date)

Master


 

 

 

 

ACADEMY OF MEDICINE OF MALAYSIA
No 19 Jalan Folly Barat
Off Jalan Ledang
50480 Kuala Lumpur
Tel: 603 2093 0100, 603 2093 0200
Fax: 603 2093 0900

PLEDGE TO BE SIGNED BY APPLICANT

I here by pledge myself as a condition of membership of the Academy of Medicine of Malaysia that I will practice my profession and conduct my life in strict accordance with the Constitution of the Academy.

I declare that I have read and agree to be bound by the Constitution and Regulations of the Academy now in force, and also to be bound by any amendments to the Constitution or any other regulations adopted from time to time by the Academy or its Council or duly delegated authority.

I declare that I will submit to any penalties including expulsion from the Academy or its Council for violation of any Articles of the Constitution or Regulations or of this pledge.
 

Date:

 

Signature:

Name: