Membership Application Form - Association of Chiropractic, Malaysia

PERSATUAN KIROPRAKTIK MALAYSIA
Association of Chiropractic Malaysia
Suite 828, Block B2, Leisure Commerce Square,
NO.9, PJS 8/9
46150 Petaling Jaya, Selangor.
Website: http:///www.chiroacm.org
Email: enquiry@chiroacm.org
---------------------------------------------------------------PPM-005-10-07122013
Membership Application Form
Surname:
Given Names:
Date of Birth:
Sex: M / F
Your designation (please highlight):  Locum
 Associate
 Principal
Other:
Contact Details
Private Address
Phone
Mobile
Postal Address
Phone
Mobile
Practice Address/es
1.
Phone
Mobile
2.
Phone
Mobile
3.
Phone
Mobile
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 Consultant
Website Address
Clinic Email Address:
 Preferred email contact (please highlight)
Personal Email Address:
 Preferred email contact (please highlight)
The Association sends out emails from time to time to notify of legislative changes, ACM award
updates, job opportunities, seminars, etc. The Association will not forward your email address
to a third party. Email addresses are published in the ACM National Contact Directory, which
is distributed to ACM members.
If you don’t wish your email address to be published in the ACM Member Directory,
(Please highlight)
--------------------------------------------------------------------------------------------------------------------------Please indicate in which category you are applying for membership (please highlight)
 Student –1st year
2nd year
3rd year
4th year
5th year
Institution attending:
 Non-Practicing
 Retiree (Over 55 years of age/20 years membership/spec circumstances)
 Academic - Give Details
 If practicing Part-Time, indicate number of hours practiced per week:
 Foreign Associate
 Full time practitioner
Primary chiropractic qualifications:
Qualification:
Institution:
Year granted:
Other academic chiropractic awards:
Award:
Year granted:
Institution:
Tertiary/post-secondary awards in other disciplines:
Qualification:
Institution:
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Year granted:
STUDENTS – go to Declaration by Applicant - Page 5
DOCTORS ONLY - Please complete the following section relating to registration
licensure:
Chiropractic Practice
State/s:
Registration no:
Date registered:
Country:
Other professional/paraprofessional registration/licensure:
Discipline:
Jurisdiction:
Please list chiropractic experience (including locums):
Location:
Dates of Practice
Location:
Dates of Practice
Location:
Dates of Practice
Location:
Dates of Practice
Location:
Dates of Practice
--------------------------------------------------------------------------------------------------------------------------What languages (other than English) are spoken in your current clinic?
--------------------------------------------------------------------------------------------------------------------------What techniques are you skilled in and used in your clinic?
(Please circle a maximum of five only) (Please highlight)
Activator
Gonstead
Nimmo
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Applied Kinesiology
Flexion Distraction
SOT
Soft Tissue
Cranial
Diversified
Drop Piece
Logan Basic
Network Spinal Analysis
Thompson
Toggle Recoil Trigger Point
What adjunctive therapies do you use in your clinic?
Nutrition
Acupuncture
Massage
Naturopathy
Homeopathy
Psychology / Counseling
Other – please specify
What areas of special interest do you have (if any)?
Sports Chiropractic
Paediatric Chiropractic
Animal Chiropractic
Chiropractic Neurology
Rehabilitative Chiropractic
Other – please specify
Details of further studies you have completed in these fields?
--------------------------------------------------------------------------------------------------------------------------Do you provide after hours/emergency care at your clinic? (Please highlight) Yes / No
Have you been disciplined by a professional association of which you were a
member?
Yes / No If yes, specify:
Have you had or are you aware of any malpractice claims against you? (Please
highlight) Yes / No
If yes, specify
Have you ever been prosecuted? (Please highlight) Yes / No
If yes, specify:
DECLARATION BY APPLICANT
I agree to abide by the Code of Ethics and Advertising guidelines of the Association of
Chiropractic Malaysia and to observe all rules and regulations of the constitution and any
amendments that are made thereto.
I agree to uphold the principles of the Association, to pay all dues as required by the
Association and to assist in all ways to accomplish the Association’s objectives.
I hereby declare that all information given in this application is true and I understand that any
misrepresentation on my part whether willful or unintentional, may cause me to forfeit my
membership of this Association.
Signature of
applicant:.........................................................................Date:…….…………………
Signature of
witness: ..........................................................................Date:……………………….
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Please tick:
 Student Fee – RM 50
 Certified True Copies of Diploma/Certificates from your college or university
 A letter of good standing from any Chiropractic Association where you have been a
member.
 A letter of good standing from the Registration or Licensing Board of any jurisdiction
where you have practiced.
 A Completed ACM Membership Application Form, attached with your photograph and
Identification Document (Identification Card for local, Passport for foreigner).
 Payment to ACM
a) For application with foreign or local working experience,
RM500 (Application Fee) [Non Refundable] and RM500 (Membership Fee. To be paid
after application is approved. Membership due end of December yearly).
b) For fresh graduated (without any working experience)
RM500 (Membership Fee. Membership due end of December yearly)
c) For ACM Student Members in First Year of Practice
RM250 (Membership Fee. Membership due end of December yearly)
 I have enclosed a cheque (please make the cheque payable to:
PERSATUAN KIROPRAKTIK MALAYSIA)
 Direct transfer to Persatuan Kiropraktik Malaysia, CIMB Bank,
Account No: 1248 0017 6660 53
(Upon completion of the transfer please scan a copy of the deposit slip/receipt and email it
to registration@chiroacm.org for confirmation of payment)
Signature…………………………………………………………………….Date……………………
Name and
Nationality…………………………………………………………………………………..
IC
No/Passport……………………………………………………………………………………………
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