Malaysian Medical Association Mps Renewal Form Page 2
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“MEDICAL PROTECTION SOCIETY”
Please issue a bank draft or cheque payable to
for the
3.
appropriate amount according to your specialty as listed and remit it to MMA with this completed form.
Marital Status :
Married
Single
Others
4.
5. Employment status :
Government
Government Specialist
Private
Private Specialist
University
University Specialist
Medical Officer
General Practitioner
6. Please complete the following particulars.
(Please Take Note That Working Address, House Address, Email and Mobile Number Is Compulsory)
WORKING ADDRESS
HOUSE ADDRESS
Postcode :
Postcode :
Tel.No. :
Tel.No. :
Fax No. :
Fax No. :
E-mail :
E-Mail :
Mobile phone no :
Mobile phone no :
7. Please state your correspondence address:
Working
House
8. Effective Date of change__________________________________
9. Please write below here if you do not wish to renew your subscription with MPS.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Signature of member: ____________________________________________
Date: ______________________________________________
FOR OFFICE USE:
Issued By Name: _____________________________________
Cheque/Online/Cash/RM: ________________________________________
Receipt No: ___________________________________________
Date of Receipt: ___________________________________________________
Comments if any: _____________________________________________________________________________________________________________________
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