PEM Membership Form

Malaysian Epilepsy Society (Persatuan Epilepsi Malaysia) aims to improve the quality of life of people with epilepsy via group effort among the medical personnel, caregivers and the patients. For PEM objectives and member's benefits, check our website: https://cutt.ly/PEM
Membership Application

To apply for membership please complete all questions.
Name*

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
IC/Passport No.*
Nationality*

MalaysianOther
Home Number

Area CodePhone Number
Cellular Number*

Area CodePhone Number
How should we contact you about our news and activities?*

I prefer via E-mail onlyI prefer via WhatsApp onlyI would like to be updated via WhatsApp and E-mail
I am a*

Person with EpilepsyCaregiverHealthcare Professional (Doctor, Nurse, Pharmacists, Researcher, etc.)Other
Membership Type*

1 Year Membership (Yearly Renewal) RM 20/yearLife Member (One-off Payment) RM 100Corporate Member (Yearly Renewal) RM 500/year
Membership Information and Benefits:
Membership Information and Benefits:
Membership Fee Payment
Or Attach Your Proof of Payment Here

Attachment

Cancelof
Should be Empty:

Membership Application