Please print (A4 portrait) & complete this form and mail, together with attachments to the address in the Contact Us webpage. 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]

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