AF-Rev2/Jan 2008
APPLICATION FORM FOR MEMBERSHIP
THE ASIA-PACIFIC ASSOCIATION OF SURGICAL TISSUE BANKING (APASTB)
NAME (Prof./Dr/Mr/Ms) Please underline your surname
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PROFESSIONAL & POSTGRADUATE EDUCATION
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PROFESSIONAL SOCIETIES MEMBERSHIP
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I enclosed herewith the membership fee of USD 150 for life member / USD 30 for yearly member.
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Signature
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Note:
Payment of registration fee is either by cash or bank transfer payable to Bank Islam Malaysia Bhd, No. 2&4, Jalan 6C/7, Bandar Baru Bangi, 43650 Selangor, Malaysia, Account Name “DR NORIMAH YUSOF/DR HASIM MOHAMAD”, Account No. 12 029 01 0023946 (Fax the payment slip to +603-89282956, Attention: Dr Norimah Yusof or email to This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).
Please send your complete form to:
Secretary: Dr Ken Urabe, Email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it
or
Treasurer: Dr Suzina Sheikh Abd Hamid, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150 Kubang Kerian, Kelantan, Email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it .
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Received by: Date:
Membership No.:
