ICD-33-F01 Rev: 1

Section XX Asia

Affix Most Recent REGION 33 MEMBERSHIP APPLICATION Passport Size Photo

APPLICANT DETAILS

______Male Female Title / Salutation Gender

______Full Name (in BLOCK LETTERS and as appears on your Identity Card / Passport) Date of Birth (DD/MM/YY)

______Permanent Address

______Postal / Zip Code City State / Province Country

______Telephone Number Mobile Number Email

______Referral Name Referral Contact Number Referral Email

______Emergency Name Contact Number Relationship

Areas of Interest: Category of Membership Training & Education FEE SCHEDULE Community Service

Social Networking

HQ ONE TIME ONE TIME ANNUAL Youth Program (ANNUAL) ENTRY INDUCTION Personal Development Please Tick  Others, please specify: ( ) *Emeritus Fellow MYR 450 - Voluntary Donation ______to Section XX Asia ( ) *Master Fellow MYR 350 - Humanitarian Fund ( ) *Honorary Fellow MYR 300 - How did you hear about ICD? ( ) *Honorary Member MYR 250 - MYR 2,000 Friend

Radio / Television ( ) *Fellow USD 40 MYR 300 MYR 300 MYR 1,000 Newspaper / Magazine

( ) Member - MYR 300 MYR 300 MYR 500 Conference Website ( ) Elite MYR 300 MYR 300 - Others, please specify: ( ) Student - MYR 100 - -

______*By Nomination / Invitation Only

Page 1 of 3

ICD-33-F01 Rev: 1

Section XX Asia

PAYMENT INFORMATION

All payments by cheque should be addressed to “INTERNATIONAL COLLEGE OF DENTISTS (ICD)”. ICD Region 33 accepts payment in the form of cash, bank draft or telegraphic money transfer. Please note that you are responsible for all bank transaction charges and currency conversion losses (if any).

Beneficiary Name : INTERNATIONAL COLLEGE OF DENTIST (ICD) Account No : 80-0699747-8 Bank Name : CIMB BANK Swift Code : CIMBBMYKL Bank Branch : STARHILL GALLERY Bank Address : STARHILL GALLERY T1, RELISH FLOOR, STARHILL GALLERY, 181, JALAN , 55100 . .

If you bank in directly, please email the scanned copy of bank-in slip to us together with the required application documents. An acknowledgement email will be received once the payment and registration is completed successfully.

Questions? If you have any questions, please contact us by email at [email protected] or by phone at +6012 686 1801 (Ms Wong Fang Ying) or +6012 522 6053 (Mr Michael Chan).

For Office Use Only:

Documents Required:

Membership Application Form Member ID: ______A copy of NRIC

Membership Fee Joining Date: ______Two Passport sized photo (most recent)

Approved Rejected KIV

Page 2 of 3 ICD-33-F01 Rev: 1

Section XX Asia

ICD REGION 33 MALAYSIA

MEMBERSHIP GUIDELINES & WAIVERS

I am applying for membership and agree to cooperate with its members in carrying on the work and mission of the ICD REGION 33 MALAYSIA within the following guidelines:

It is my responsibility to conduct my personal affairs in a manner that affirms the mission of the ICD REGION 33 MALAYSIA.

In consideration of my participation in the activities of the ICD REGION 33 MALAYSIA, I do, for myself, my heirs, executors and administrators, waive any and all claims for damages for any injury to myself which may have been sustained arising out of or connected with such participation and I release and discharge the ICD REGION 33 MALAYSIA, its members, officers, employees, or agents from any and all liability whatsoever arising out of or connected with such participation.

The ICD REGION 33 MALAYSIA reserves the right, but assumes no obligation, to conduct background checks on all applicants for membership.

I do hereby declare myself to be physically sound having medical approval to participate in the activities of the ICD REGION 33 MALAYSIA.

CODE OF CONDUCT

The ICD REGION 33 MALAYSIA is committed to providing a safe and welcoming environment for all members and guests. Conduct that does not support the ICD REGION 33 MALAYSIA mission and core values are not acceptable.

Be responsible You are responsible for your behaviour. If you have a concern or problem, please contact ICD REGION 33 MALAYSIA staff personnel. Be caring No fighting, physical or verbal confrontation is allowed in ICD REGION 33 MALAYSIA programs or facilities. Refrain from abusive or profane language. Always be mindful in your choice of words. Be respectful Intentional damage to another person’s property or ICD REGION 33 MALAYSIA property will not be tolerated. Mistreatment or harassment of ICD REGION 33 MALAYSIA members or staff is strictly prohibited. Be honest You are expected to be honest and professional with other members and staff by your activating leadership and demonstrating integrity. Be healthy Unsafe or dangerous behaviour will not be tolerated. Your ICD REGION 33 MALAYSIA is a safe zone. Use or possession of drugs, alcohol or weapons is not allowed in ICD REGION 33 MALAYSIA programs or facilities. No smoking is allowed in ICD REGION 33 MALAYSIA facilities.

Violation of these guidelines may result in suspension or revocation of membership.

PHOTO / VIDEO RELEASE

For my participation in activities to be conducted by the ICD REGION 33 MALAYSIA, I hereby give my permission and consent, now and for all time, to the ICD REGION 33 MALAYSIA, ICD HQ (Michigan, USA) and third parties collaborating with the ICD REGION 33 MALAYSIA and/or ICD HQ to make, reproduce, edit, broadcast or rebroadcast any video film, footage, sound track recordings and photo reproductions of me on my account and/or my narrative account of my experience at the ICD REGION 33 MALAYSIA, for publication, display, sale or exhibition thereof in promotions, advertising and legitimate business uses without any compensation to, and/or claim, by me. I may or may not be, identified in such reproductions; however, I shall not be stated by name to have endorsed any particular commercial products or commercial services.

______Applicant Name Applicant Signature Date of Application Page 3 of 3