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AMM Membership Application Form 2023

The document appears to be an application for membership to the Academy of Medicine of Malaysia. It requests information such as the applicant's name, address, qualifications, publications, and references. It also provides details on the requirements and fees for ordinary membership, associate membership, and life membership. Applicants are required to submit certified copies of their qualifications and pay the appropriate entrance and annual/life membership fees.

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Nurul Nadiah Mohd Ali
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93 views7 pages

AMM Membership Application Form 2023

The document appears to be an application for membership to the Academy of Medicine of Malaysia. It requests information such as the applicant's name, address, qualifications, publications, and references. It also provides details on the requirements and fees for ordinary membership, associate membership, and life membership. Applicants are required to submit certified copies of their qualifications and pay the appropriate entrance and annual/life membership fees.

Uploaded by

Nurul Nadiah Mohd Ali
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Academy of Medicine of Malaysia

APPLICATION FOR MEMBERSHIP


1. Title: _____________________________________________________________

2. Name in full :_______________________________________________________


(in BLOCK letter)

3. Home Address:______________________________________________________

__________________________________________________________________

__________________________________________________________________

Tel No: ______________ Fax No: ___________ E-mail: ____________________

4. Practice Address:_____________________________________________________

__________________________________________________________________

__________________________________________________________________

Tel No: ______________ Fax No: ___________ E-mail: ____________________

5. Preferred mailing address : Home  Office 

6. Date of Birth :____________________________

7. IC No. (Malaysian citizen) :_______________________________________________

Citizenship and Passport No. (Non-Malaysian) :_______________________________

8. Category of membership applied for (please tick appropriate box):


Ordinary  Life  Associate 

9. National Specialist Register (NSR) No:___________________

10. Qualifications (please enclose certified true copies of certificates):

Degree/Diploma Institution Year

_____________________ ________________________________ ______________

_____________________ ________________________________ ______________

_____________________ ________________________________ ______________

11. Present Appointment: __________________________________________________

12. 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

_____________________ _______________ _______________________________

_____________________ _______________ _______________________________

_____________________ _______________ _______________________________


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

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

14. 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: _______________________________________________________________

______________________________________________________________________

Please find enclosed:

 Cheque No: ______________________ RM________________


(in favor of Academy of Medicine of Malaysia)

 Cash: ___________________________

Date: __________________________ Signature: ______________________


RECOMMENDATION OF COLLEGE

The Council of the College of _______________________________________________

recommends that ________________________________________________________

has fulfilled all the membership admission criteria and be admitted as an ordinary
member / associate member of the Academy of Medicine of

Malaysia and his / her name be listed as a member of the College of ________________

_______________________________________________________________________

___________________________________ _______________________________
President Hon Secretary

Name ______________________________ Name __________________________

Date _______________________________ Date ___________________________

OFFICE USE ONLY

Verified by Board of Censors

On_________________________ ____________________
Chief Censor

Approved

on (date)____________________ ____________________
Master
ACADEMY OF MEDICINE OF MALAYSIA

Unit 1.6, Level 1, Hive 4


Taman Teknologi Mranti,
Lebuhraya Puchong - Sg Besi,
Bukit Jalil, 57000 Kuala Lumpur

Tel: (603) 8996070/1700/2700 Fax: (603) 89664700


Email: [email protected]

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: _________________________
ACADEMY OF MEDICINE OF MALAYSIA
APPLICATION FOR MEMBERSHIP

BANK DETAILS

The fees can be paid via online transfer / cheque / remittance to our account below:-

Acc Name : Academy of Medicine of Malaysia


Acc No : 8731 0377 3485
Bank : Standard Chartered Bank
Lot 4&5, Level G2 Publika Shopping Gallery
Solaris Dutamas
50480 Kuala Lumpur
Wilayah Persekutuan Kuala Lumpur

Kindly share with us a copy of the transaction slip for receipt issuance and record
update.

Ordinary / Life / Associate Membership

Fully registered medical or dental practitioners who

 are certified to be specialists by the appropriate authorities,


 have a recognized postgraduate or higher qualifications and are of good character
and conduct
 have been testified by three referees, two of whom must be members of the
Academy of Medicine of Malaysia
 have registered with National Specialist Register (NSR)

Notwithstanding the criteria above, the Council may admit

 qualified members of the medical or dental professions of at least twenty years


standing, engaged in medical/dental practice provided that not more than ten
such members shall be admitted in any one financial year.
 qualified members of the medical or dental profession holding higher academic or
professional qualifications (eg MD, DMedSc, PhD, Board Certification) provided
that they have contributed significantly to medicine.
 persons without a medical qualification but engaged full time in a medical
discipline, provided that such persons shall hold academic or professional
qualifications equivalent to a PhD and have contributed significantly to medicine.

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.
Please attach:

Ordinary / Associate Member


- Certified true copies of
a. Basic Medical Degree(s)
b. Postgraduate qualification(s)
c. National Specialist Register (NSR) certificate

- Cash / Cheque / Online transfer for RM650.00 - entrance fee (RM500.00) and
annual subscription (RM150.00)

Life Member
- Certified true copies of
a. Basic Medical Degree(s)
b. Postgraduate qualification(s)
c. National Specialist Register (NSR) certificate

- All members except Honorary Fellows may become Life Members by donating to
the Academy the following sums:

Above 50 years old


 Cash / Cheque / Online transfer of RM1500.00 - entrance fee (RM500.00)
and life member subscription (RM1000.00)

50 years old and below


 Cash / Cheque / Online transfer of RM3000.00 - entrance fee (RM500.00)
and life member subscription (RM2500.00)

Life Members shall be exempted from payment of annual subscriptions.

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