MALAYSIAN
PHYSIOTHERAPY ASSOCIATION
  Professional Body Representing
Malaysian Physiotherapists
 
 
Application for registration - Malaysian Nationality
 
   
* Please Use Internet Explorer To Do Registration *
   
 
Section 1 : Personal Details    
     
   
     
Title Mr/ Mrs/ Miss/ Ms/ Dr/ Other (Please Specify) :
Decoration Dato/Datin/Tan Sri (Please Specify) :
Name :
IC No :
Date Of Birth : (Format : DD/MM/YYYY)
Country Of Birth :
Town / City Of Birth :
Gender :
     
Home Contact Details    
     
House Number :
Street Name :
Town / City :
State :
Postcode :
Country :
Telephone Number : +6
Mobile Number : +6
Email Address :
     
Section 2 : Work Contact Details    
     
Organization :
Department :
Street Name :
Town / City :
State :
Postcode :
Country :
Telephone Number : +6
Mobile Number : +6
Email Address :
Fax No :
Web URL :
     
Sector :
     
    If Others, Please Specify :
Section 3 : Education and Training    
     

Title of your relevant qualification

:
Year Of Completion *Last year of latest qualification : (Format : YYYY)
Name of educational institution :
Street name :
Town/city :
State :
Postcode :
Country :
Telephone No :
Fax No :
Website URL :
     
Section 4 : Details Of Character Referee
     
Before being registered an applicant must satisfy the MPA that they are of good character. A character reference must be provided on this form by a person of standing in the physiotherapy profession who is not a relative of the applicant and who has known the applicant for at least three years.
     
Name :
Practice or business address :
Telephone :
Email address :
     

If Reference if made By MPA, MPA Membership No

:
     
I confirm that I have known the referee for year(s) and I confirm that the information that I have provided is accurate and I agree that in order to process my application, I give permission to MPA to refer my data to the referee mentioned above or anybody MPA EXCO may consider suitable for verification purposes.

NOTE: MPA may make further enquiries in respect of the applicant and referee, to verify or clarify information about the applicant and your reference. Should any of the information you have supplied in this reference not be accurate or if you have made any false claims, you may be committing a crime.

MPA may contact you to ensure that your reference is accurate and may also disclose your personal data to third parties to check its accuracy, including but not limited to checking that you are a member of the MPA. Should any inaccuracies be established, your personal data may be transferred to a third party for further investigation. Should a registrant transfer to another country, your reference may be passed to any appropriate regulators in that country.


  I Agree And Confirm That The Information That I Have Provided Is Accurate And That My Personal Data May Be Processed For The Purposes Specified Above.
     
Attachments :    
 

[ Recent Photo - Please make sure its a jpeg image with maximum size 30KB ]
[ Latest certificate attested by Principal or Class I officer or a oath commissioner ]
[ Proof of Payment ]
[ Other Document ]
[ Other Document ]
[ Other Document ]


     
MPA Account Detail :
Name: Persatuan Fisioterapi Malaysia
Account No: 1416-0009525-05-8
Bank: CIMB Bank
   
     
 
 
 
Copyright @ Malaysian Physiotherapy Association