MALAYSIAN PRIVATE DENTAL PRACTITIONERS' ASSOCIATION (MPDPA)

MEMBERSHIP APPLICATION FORM

I wish to apply to be a member of the Malaysian Private Dental Practitioners’ Association /MPDPA.

  1. NAME :…………………………………………………………………………………………………
    (in block letters, surname underlined)

  2. I/C NO: …………………………………………………………………………………………………

  3. ADDRESS WITH POST CODE:

    OFFICE: …………………………………………………………………………………………………

    TEL:………………………………… FAX: …………………………………

    EMAIL: …………………………………………………………………………………………………

    HOUSE: …………………………………………………………………………………………………

    TEL: ………………………………… FAX: …………………………………

  4. DENTAL QUALIFICATIONS: BASIC…………………………ADDITIONAL………………………

  5. MALAYSIAN DENTAL COUNCIL (MDC) REGISTRATION:

    DATE REGISTRATION :……………… PLACE REGISTRATION: …………………………

    MDC REG NO: ………………………

  6. MDA MEMBER:       [   ] YES       [   ] NO

    SINCE: …………… MEMBERSHIP NO:………………….


…………………………………                                                    …………………………………
              DATE                                                                                 SIGNATURE


ENTRANCE FEE : RM50     ANNUAL SUBSCRIPTION : RM50
             
TOTAL TO PAY AS NEW MEMBER : RM100

  • CROSSED CHEQUES MADE PAYABLE TO "M.P.D.P.A"
  • OUTSTATION CHEQUES KINDLY ADD BANK COMMISSIONS.
  • PLEASE SEND THE COMPLETED FORM TO THE FOLLOWING ADDRESS:
MALAYSIAN PRIVATE DENTAL PRACTITIONERS’ ASSOCIATION (MPDPA)
25A, BT. 5. JALAN BESAR AMPANG, 68000 AMPANG, SELANGOR.
TEL: 03-4257 2542 / 2282 2402 FAX: 03-4257 1542 EMAIL: [email protected] / [email protected]
(Attn: Hon. Secretary - Dr Larry Au-Yong)
.