Member Registration Practicing/Non-PracticingPracticing/Non-PracticingRM80.00MASH Membership Registration FormDECLARATIONS * I hereby declare that the below statements are true to the best of my knowledge and belief.Yes* I declare I have not been investigated or subjected to censure or prosecution, in a civil or criminal context Yes* I declare my commitment to maintaining my knowledge and competence and expertise through active engagement in a range of professional development and activities. I agree to engage in a programme of continuing professional development of which I am keeping an up-to-date record. Yes* I agree to abide by the standards and guidelines of the MASH and Code of Ethics.Yes* Are you a former MASH Student Member?YesNo* Please select appropriate Membership CategoryPracticing MemberNon-practicing Membera) Practicing: Registered with MAHPC and possess annual license to practice b) Non-practicing: Registered with MAHPC but does not possess annual license to practice NOTE: MAHPC: Malaysian Allied Health Professions Council Until the end of June 2025, which is the transition period set by MAHPC, all active MASH members will be categorized as “Practicing” member. PERSONAL INFORMATION Please make sure your information is complete and correct. You will be contacted by MASH with the information you provide below, including your Membership Confirmation Email. * ProfessionSpeech-Language TherapistAudiologist * Full Name* GenderMaleFemale * Date of Birth * NationalityNote: Non-Malaysian applicants will be considered as ‘Associate Members’ of MASH * MyKad No. or Passport No* Personal PhotoDone(Use Cropper to set image and use mouse scroller for zoom image.)Done(Use Cropper to set image and use mouse scroller for zoom image.)Drop file here or click to select. * Mobile Phone Number * Correspondence Address (Street Address) * City * Postcode* StateJohorKedahKelantanMelakaPahangPenangPerakPerlisNegeri SembilanSabahSarawakSelangorTerengganuWP LabuanWP Kuala LumpurWP PutrajayaOther * State* Country/RegionCountry/RegionAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongoCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceFrench GuianaFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe * Country/Region BiographyTell more about yourselfREFEREES All applicants are required to provide two referees (preferably members of MASH) to whom MASH EXCO may refer to for information relating to your qualification, training and experiences. You may submit your university academic’s name and/or your work colleague’s, who have been worked together with you for a minimum of 2 years as your referee. * Name of Referee 1 Professional Membership ID of Referee 1 * Email of Referee 1 Phone Number of Referee 1 * Name of Referee 2 Professional Membership ID of Referee 2 * Email of Referee 2 Phone Number of Referee 2MAHPC INFORMATION * Do you have a valid MAHPC annual practicing license?YesApplied but pending for approvalNo MAHPC Registration IDMAHPC Registration certDrop file here or click to select. MAHPC License No. MAHPC License Validity DateUpload your MAHPC License CertDrop file here or click to select.EDUCATIONAL INFORMATION * Qualification 1(eg. Masters of Speech Sciences, Bachelor of Audiology etc.) * Name of University 1 * Year of Graduation 1* Copy of Certificate AwardedDrop file here or click to select.* Copy of TranscriptDrop file here or click to select. Qualification 2 Name of University 2 Year of Graduation 2Copy of Certificate Awarded 2Drop file here or click to select.Copy of Transcript 2Drop file here or click to select.WORK INFORMATION * CaseloadsPaediatricsAdults* Work settingsGovernmentNGOPrivateHouse Call / Home VisitTeletherapy* Employment StatusYesNoSelf-employed * Employment StatusKindly upload your SSM certificate for self-employmentDrop file here or click to select.* StatesJohorKedahKelantanMelakaPahangPenangPerakPerlisNegeri SembilanSabahSarawakSelangorTerengganuWP LabuanWP Kuala LumpurWP Putrajaya Area CoveredEg: Bangi, KajangEMPLOYMENT DETAILS * Job Title * Work Phone Number * Work Email * Name of Company 1 * Street Address of Company 1 * City of Company 1* State of Company 1JohorKedahKelantanMelakaPahangPenangPerakPerlisNegeri SembilanSabahSarawakSelangorTerengganuWP LabuanWP Kuala LumpurWP PutrajayaOther * State of Company 1 * Postcode of Company 1 Weblink of Company 1 Name of Company 2 Street Address of Company 2 City of Company 2State of Company 2JohorKedahKelantanMelakaPahangPenangPerakPerlisNegeri SembilanSabahSarawakSelangorTerengganuWP LabuanWP Kuala LumpurWP PutrajayaOther State of Company 2 Postcode of Company 2 Weblink of Company 2LISTING IN DIRECTORY * To be listed in directory?NoYes * To be listed in directory?AREA OF INTEREST OR SPECIALIZATION * Area of Interest or Specialization (you may tick more than one)AudiologyAugmentative and Alternative Communication (AAC)AphasiaAutism Spectrum Disorder (ASD)DysphagiaSpeech DyspraxiaDevelopmental Language DisorderStutteringVoiceOtherCREATE MEMBER PORTAL ACCOUNT * Email Address * PasswordStrength: Very Weak * Confirm PasswordBy clicking SUBMIT you hereby agree with and consent to us processing/continuing to process your Personal Data in accordance herewith. Select Your Payment GatewayBillplzHow you want to pay?Auto Debit PaymentManual PaymentPayment SummaryYour currently selected plan : Plan Amount : Non-refundable Processing Fee: 50.00 MYR (Only applicable for new registration) Please click ‘Submit’ to see final payable amountSubmit
