LCP Chapter 3 Application Form

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Membership Application for *

Type of Membership *

As per Identity Card

As per Identity Card (XXXXXX - XX - XXXX)

Marital Status*

Single Married Others

Nationality*

Malaysian Others

Example: user@gmail.com

Professional Qualifications *

Date of Qualification *

Set working address as my correspondence address

Entrance Fee (For New Membership only)

Full Membership - MYR100 Resident Membership - MYR50

Annual Fee (Annual fees have to paid to the treasurer before the first 31st day of January every year)

Full Membership - MYR100 Resident Membership - MYR50

Payment Confirmation

Account No: 86-0005729-8

Name of Account:

Pertubuhan Pembedahan Plastik
dan Rekonstruktif Malaysia

Upload all documents and proof of payment in pdf or jpeg format, not more than 2000KB or 2MB file size.

A photograph (passport size)

All payments are payable to "Malaysian Society of Plastic & Reconstructive Surgery"

In submitting an application for membership of the club, I agree to abide by the regulation as may be enacted from time to time.

I'm not a robot

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LCP Chapter 3 Application