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PERSATUAN PAKAR ORTODONTIK MALAYSIA (MALAYSIAN ASSOCIATION OF ORTHODONTISTS)
PLEASE TYPE OR WRITE IN BLOCK LETTERS AND TICK WHERE APPROPRIATE
APPLICATION FOR:-
ORDINARY MEMBERSHIP ASSOCIATE MEMBERSHIP
INTERNATIONAL MEMBERSHIP STUDENT MEMBERSHIP For Office Use Reg. No.
Name:
NRIC: Passport No:
Date of Birth: Place of Birth: Nationality:
Residential Address:
Tel No: Mobile: Email:
Correspondance Address (if different from above):
Dental Qualification (in full):
University: Month/Year:
Orthodontic Qualification (in full):
University:
Month/Year: Duration of Training: _______________ Year in training:_____________________________________
Techniques: Lingual SWA and variations Edgewise
Functional Self ligating Others:_______________
Employer’s Name:
1) Main Practice Adress:
OfficeTel No: Fax No:
2) Branch Practice Address:
OfficeTel No: Fax No:
3) Branch Practice Address:
OfficeTel No: Fax No:
I hereby declare that the above information is true and correct. I enclose one copy of each of my dental
and post-graduate qualifications which have been certified true copies by my proposer.
Applicant's Signature: Date:
FOR ORDINARY / INTERNATIONAL / ASSOCIATE MEMBERSHIP
Proposed by (MAO Member):
I hereby declare that ______________________________________________________________ is, to
the best of my knowledge, a qualified orthodontist of good character and the copies of his / her
qualifications are true copies of the original documents.
Proposer’s Signature:
Date:
Seconded by (MAO Member): Seconder’s Signature: Date:
FOR STUDENT MEMBERSHIP
Proposed by (MAO Member and Head Of Department): ____________________________________ I hereby declare that ______________________________________________________________ is, to the best of my knowledge, a post-graduate in training in Orthodontics and of good character and the copies of his / her qualifications are true copies of the original documents. Proposer’s Signature: Date: Kindly enclose the following with your application form:
(1) Bank draft / cheque crossed and made payable to PERSATUAN PAKAR ORTODONTIK MALAYSIA
Fees for Ordinary / International / Associate Membership: (1) Entrance Fee: MYR 400.00 (2) Annual Fee: MYR 200.00
Total = MYR 600.00 (Ringgit Malaysia Six Hundred Only)
OR
Fees for Student Membership:
Annual Fee: MYR 100/= (Ringgit Malaysia One Hundred only) (Note: Please add MYR 2.50 for bank charges for ALL payment by cheques)
(2) One (1) copy of each of your dental and post-graduate qualifications, each copy signed and certified true copy by
your proposer. For student membership, one copy of each of your dental qualification and letter to verify currently in
post-graduate training, each copy signed and certified true copy by your proposer.
(3) Two (2) copies of a current passport size coloured photographs protected in plastic envelope.
(4) A copy of your current Annual Practicing Certificate (APC).
(5) A copy of a valid International Passport/ Malaysian Identity Card.
(6) Additional for Associate Membership: A copy of Malaysian Dental Council Registration number (MDC No.) and a
letter of good standing/support from your home National Orthodontic Association.
Please mail to: MAO Secretariat No: 21-3A, 2nd Floor, Block L, Jalan PJU 1/3C Sunway Mas Commercial Centre 47301 Petaling Jaya, Selangor Darul Ehsan MALAYSIA
PleasenotethattheMAOSecretariatisnotmanned.DONOTsendanyregisteredmailtothesecretariat.Forallqueries,pleaserefertotheHon.Secretaryatsecretary@mao.org.my
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