Applicant Particulars * Category of MembershipOrdinaryAssociateLife * Category of Membership Membership ID * Title * Full Name* GenderMaleFemale * Email Address * Correspondence Address * City * State * Postcode * Mobile No. Tel. No. (Office) Tel. No. (Home) * Date of Birth * New IC No. * Preferred PasswordStrength: Very WeakQualification * Name and abbreviation of Qualification (Degree/Diploma) [1] * Institution name [1] * Year of completion [1] Name and abbreviation of Qualification (Degree/Diploma) [2] Institution name [2] Year of completion [2] * Present Appointment & AddressRecommendation Proposed and seconded by (Must be members of the Society) * Proposed - Name * Proposed - Address Seconded - Name Seconded - AddressPayment Method CashChequeCash Send proof of payment to secretariat@msic.org.my Cheque Send completed form with cheque to : Malaysian Society of Intensive Care Unit 1.6, Level 1, HIVE 4, Mranti Park Jalan Innovasi 1, Bukit Jalil, 57000 Kuala Lumpur, Malaysia Payment Details Name Of Account: Malaysian Society of Intensive Care Number Of Account: 873-1-5662806-4 Name Of Bank: Standard Chartered Bank Berhad Address Of Bank: Kuala Lumpur Branch, Lot 4&5, Level G2, Publika Shopping Galley, Solaris Dutamas, 50480 Kuala Lumpur Swift Code: SCBLMYKXXXX Payment ProofDone(Use Cropper to set image and use mouse scroller for zoom image.)Done(Use Cropper to set image and use mouse scroller for zoom image.)Drop file here or click to select.SubmitAlready have an account? Login
