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Dear friends,

MDA welcomes you to be the members. Before you start filling up this print out application form, please spent a few moment to read through the regulation in the membership section.

Thank you.

 

Personal Information:
Name (as in I.C.)
:
Email
:
Mailing Address
:
Postal
:
Date of Birth
:
Place of Birth
:
I.C. No
:
Sex
:
Phone (Office)
:
Phone (Home)
:
Mobile
:
Qualification Details:
Qualification
:
Date
:
Place
:
MDC Registration No
:
Field of Specialization
:
Indicate Category of
Practice
:
Govermnent Armed Forces
University Private
If Other,
Please state
:
Agreement:

I hereby apply for the following membership in the M.D.A. and undertake to abide by its constitution & bye-laws. Please tick the relevant box.

I agree with the Terms and Conditions *
Others Details:
ORDINARY
:
LIFE
:
ASSOCIATE
:
CORRESPONDING
:
Order:
Order for
the sum for RM
:
Entrance - RM100
Subscription - RM100
Payment Amount
:
Payment by credit card :
Please Provide Us Your Credit Card Information
Name on Card
:
Zip/Postal Code
:
Card Type
:
Visa
Master Card
If other, please write:
Card Number
:
Exp. Date(Month)
:
Exp. Date(Year)
:
CVV Number
:
MDA staff will contact you for the number. Please hold.
Please be sure to charge to your Virtual card
if you pay by Direct Access Card

 

 

 

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MALAYSIAN DENTAL ASSOCIATION
54-2 (2nd Floor) Medan Setia 2
Plaza Damansara, Bukit Damansara, 50490 Kuala Lumpur
Tel: 603-20951532, 20951495
Fax: 603-20944670
Email: mda@streamyx.com

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