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  i01 M3C 9.0 Conference  
   
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APPLICATION FORM FOR MEMBERSHIP

Full Membership (Registered medical practitioner are engaged in private practice)
Affiliate Membership (Registered medical practitioner but engaged in NON-private practice)

Surname : Given Name (in full) :
Chinese Name : Title (Prof./Dr etc) :
Date of Birth : - - Gender : Male Female
  (dd-mm-yyyy)    
Office Tel. : Office Fax :
Office Address :
 
 
 
E-mail :
Home Tel. : Mobile :
Home Address :
 
 
 
Preferred Address for correspondence: Office Home
 
Academic & Professional Qualifications:-
Degree(s) / Qualifications Name of Institution Year obtained
       
Specialty :
Special area of interest in your specialty :
       
   
   
 
 

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