Membership Application Form Return to: MSA secretariat, 19 Jalan Folly Barat, Off Jalan Ledang, 50480 Kuala Lumpur Email: acadmed@streamyx.com     http://www.msa.net.my     Fax: 603-2093 0900 Title: Dr. / Assoc. / Prof / Dato' / Tan Sri Name: NRIC (New): NRIC (Old): Race: Nationality: Sex: Male Female Marital Status: Single Married Others Work Address: Work Town: Work Postcode Work State: Work Phone: Work Fax: Home Address: Home Town: Home Postcode Home State: Home Phone: Mobile Phone: Mailing Address: Send to: Home address Work address Email: Practice Type: Government University Private Practice Status: Trainne Specialist Special Interest: Qualifications: 1. Qualification:   Institution:   Year of Award:       2. Qualification:   Institution:   Year of Award:       3. Qualification:   Institution:   Year of Award: Referees: 1. Referees:   Address:   Position:       2. Referees:   Address:   Position:       3. Referees:   Address:   Position:

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