Life Membership Registration

Application Overview

This form is divided into sections. You can scroll normally — the sidebar is a guide.

Personal Name, gender, contact

MAHPC License + supporting doc

Education Level + certificate

Work Sector, state, specialty

Directory Listing consent

Account Username, password, avatar

If MAHPC = Yes, Registration Number and Certification upload will appear automatically.

1) Personal Information

Required

Full Name *

Gender *

Email *

We will use this email for official communication.

Date of Birth *

IC Number (Without -) *

Typing IC will auto-fill Username later.

Phone Number *

Postal Address *

2) MAHPC Information

Conditional fields

Do you have a valid MAHPC annual practicing license? *

If “Yes”, registration number and certification upload will appear.

3) Education Information

Required

Level of Education *

Academic Qualification *

Academic Certification *

Choose File

Upload a clear copy (PDF/JPG/PNG).

4) Work Information

Required

Workplace *

Position *

Sector *

States *

Area of Specialty *

Select “Other” to specify your specialty.

5) Listing in Directory *

Required

Do you want to be listed in directory?

Your listing may appear in the official directory if approved.

6) Create Member Account

Required

Username *

Auto-filled from IC Number.

Password *

Keep your password private.

Avatar *

Choose image

Upload a clear profile image.