PERSATUAN KESIHATAN MENTAL MALAYSIA APPLICATION

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PERSATUAN KESIHATAN MENTAL MALAYSIA
Malaysian Mental Health Association

Registration No. 403 (Selangor). 
Peti Surat No. 725, Jalan Sultan, 46780 Petaling Jaya, Selangor, Darul Ehsan
Tel: 03-77825499 Tel/Fax: 03-77835432 E-mail: mmha@streamyx.com

APPLICATION FOR MEMBERSHIP
I wish to apply for Membership with your Association and I undertake to observe the Rules and Constitution of the Association. I am a Malaysian Citizen and over 18 years old and my personal particulars are as follows:-
Name: Dr/Mr/Mrs/Miss _____________________________________   Male  Female

NRIC No. _____________________________________       Age: ____________________

Date of Birth: _______________________          Place of Birth: ____________________
Correspondent Address: _____________________________________________________

___________________________________________________  PostCode: ____________

Tel No. (o)__________________ (h)__________________ ( Fax )  __________________

Profession/Occupation: _________________________  Email: ______________________

I wish to offer my service as follow:
(a) _________________________________  (b) _________________________________

Date: _____________________                                   ______________________
Signature of Applicant

Fees/Subscription
Please tick which is applicable and forward the remittance with your application
 

Full Member Entrance Fee
Annual Subscription
RM 2.00
RM 20.00
Life Member Entrance Fee
Subscription (one-time)
RM 2.00
RM 200.00
Associate Member
(Association/Organisation/Company)
Entrance Fee
Annual Subscription
RM 2.00
RM 500.00

Proposed by                    Seconded by
Name: ______________________________ ___________________________________

Signature:  __________________________

___________________________________


(N.B) Rule 4.3 in the Rules & Constitution: “4.3.1 Every application for membership shall be proposed and seconded by two existing Full Member …” Leave blank if you do not know of any proposer or seconder.
The secretariat will arrange for you.