MSCH Registration Form

Malaysian Society of Clinical Hypnosis Membership Form
Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Mobile Number*
Qualifications (ie. BSc Psych) *
Profession *
Type of Membership *
Period of Membership

AnnualLifetime
Name to be written on MSCH Membership Certificate
Additional Comments / Questions
By applying for membership with the Malaysian Society of Clinical Hypnosis (MSCH), I affirm that I have met the eligibility criteria corresponding to the membership category for which I am applying. I agree to uphold the MSCH's ethical code of conduct and professional standards at all times.

With this I enclose the membership fee to:

PERSATUAN HIPNOSIS KLINIKAL MALAYSIA

Bank: UOB Malaysia | Account Number: 2093069937
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Malaysian Society of Clinical Hypnosis Membership Form