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