SMA Membership Application

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Application Date
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23/02/2019
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Membership Type*
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PERSONAL PARTICULARS
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Salutation*
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NRIC Type*
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NRIC/Passport/FIN No.*
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Name* (as in NRIC/Passport/FIN)
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MCR No.* (Students please indicate matriculation number)
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Nationality*
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Date of Birth* (DD/MM/YYYY)
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Race*
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Religion*
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Gender*
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Marital Status*
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Hobbies / Interests
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How did you get to know about SMA?
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Referral Name
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Referral MCR No
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Private Email(User ID)*
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Password*
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Confirm Password*
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Preferred Mailing Address*
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PRACTICE CONTACTS
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Information entered here will be listed in our Online Directory of SMA Doctors if you enabled the option. Members of the public will be able to search for your practice and view all information provided under “Practice Contacts”.
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Name of Clinic/Institution*
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Address line 1*
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Address line 2*
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Address line 3*
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Postal Code*
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Country
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Phone
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Fax
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Email
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Website
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Opening Hours
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HOME CONTACTS
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Address line 1*
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Address line 2
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Address line 3
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Address line 4
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Postal Code*
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Country
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Phone
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Hp
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Fax
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PROFESSIONAL QUALIFICATIONS
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Professional Qualification
(registerable with SMC)
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Country of Graduation
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Medical School/University
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Year of Graduation*
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Area of Practice
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Specialty
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Sub-specialty
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Sub-specialty
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Designation/Position Held
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Rates
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