Untitled Document

CONSULTANT COMMUNITY PHARMACIST MEMBERSHIP APPLICATION FORM B ( New )

Section A

Titles: Mr/Mrs/Miss/Dr/Prof/Datuk/Others

Full Name (as in NRIC)

NRIC No

Home Address

Pharmacy Address

Telephone (H) (O) (H/P)

Fax Email

Section B

Pharmacy qualifications

Year qualified University/Institution

Malaysian Pharmacy Board Registration Number

Year Obtained

Community Pharmacy Practice Particulars

Professional Assessment Evidence

Section C

Payment Ref.(Bank & cheque number)

(Annual Membership Fee: Rm200.00; Entrance Fee:Rm20.00 (pay once)

Note: MCPA’s current account NO: PBB-(3134651812)