MPDPA Membership Application

Malaysian Private Dental Practitioners' Association

Complete the form below to register as member.
Name*

First NameLast Name
E-mail*
MPDPA NEW MEMBERSHIP REGISTRATION FORM

Dear Colleague,
Welcome on board!

To proceed with your registration, kindly fill and submit this google form.

Please make the necessary payment :
New Membership (one time Registration fee ) : RM150
Membership Renewal Fees : RM 100 (annually)
Dental Student Membership : RM 30.

Kindly make an online payment to : Malaysian Private Dental Practitioners' Association
MAYBANK Account : 5641 2843 0729.

Do email us your proof of payment along with a copy of your APC ( Annual Practicing Certificate ) to : mpdpa1@gmail.com

Your E-Receipt will be sent to you at the contact details provided.

Thank You!
MDC Number*
Phone Number*

Area CodePhone Number
NRIC/Passport No*
Clinic Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Upload your current MDC certificate (Perakuan Pendaftaran )*

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Upload your current or last year’s APC *

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Upload your InCharge C/G – for clinic owners / Person InCharge (PICs)

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Upload Proof of Payment*

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Membership Type*

Ordinary MemberLife Member
Preferred way to contact

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Privacy Policy
Please reach out and read our Privacy Policy in order to understand how your information is used and shared, and check below if you accept the policy.*

I have read, understood, and accepted the PRIVACY POLICY for membership.
Once you submit your application, we will contact you shortly to complete your membership application.

Thank you!
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Malaysian Private Dental Practitioners' Association

Privacy Policy