Malaysian Thoracic Society Registration

Malaysian Thoracic Society - Registration This page is under a secure server.

Please specify the login settings to your account. Upon successful registration, you can log into the system anytime to change or update your details.
User Name*:
Password*:
Confirm*:
Private Question:
	e.g.: What is your mother's maiden name?
Answer to Question:
Account Type:	Ordinary Member Ordinary Life Member Affiliate Member Affiliate Life Member

Registration Information

Please use your name and personal details as per your IC/Passport.
Title:
Full Name*:
NRIC / Passport No.*:
Email*:
Confirm Email:	(typo checking, don't copy-paste)

Preferred Phone Contact*:
Mobile Phone No.:
Work Phone No.:
Home Phone No.:
Fax:
Date of Birth:	format (dd/mm/yyyy)
Place of Birth:
Nationality:
Sex:

Name of Institution*:
Department:
Position:

Malaysian Medical Council No:

Qualifications
First Degree/Diploma
Awarding Body:
Year:

Postgraduate Qualifications
Specialty:
Awarding Body:
Year:

Specialty:
Awarding Body:
Year:

Specialty:
Awarding Body:
Year:

Specialty:
Awarding Body:
Year:

My membership application is proposed by*:	(needs to be an existing member)
	Please note that your application will not be accepted without a valid Proposer.

Your Address

Working Address
Address Line 1*:
Address Line 2:
Address Line 3:
Address Line 4:
Address Line 5:
Address Line 6:
City*:
State*:
Postal Code*:
Country*:

Home Address
Address Line 1
Address Line 2
Address Line 3
City:
State:
Postal Code:
Country:

Preferred correspondence address

Please note that your application will only be processed after you have made payment for the membership fee.