Membership Registration – Local

Membership Type

Clear

Title *
Surname *
Other Names *
Date of Birth *
Sex *	Male Female
Postal Address *
Contact Number - Home
Contact Number - Mobile *
E-Mail *
NIC/Passport Number *
SLMC Registration No / Medical Faculty Registration No (For Student Membership) *
Year of Graduation (MBBS/Basic Degree) / A/L Year (For Student Membership) *
Qualifications / Name of Medical Faculty (Student Membership) *
Current Position / Designation / Student Membership: Enter 'Not Applicable' *
Place of Work / Student Membership: Enter 'Not Applicable' *

Below section is mandatory for Life Memberships and Ordinary Memberships. Not required for student Memberships.
**The proposer and seconder should be members of the SLMA
**Name of Proposer
Mobile number of Proposer
Email of Proposer
**Name of Seconder
Mobile number of Seconder
Email of Seconder

SKU: 100 Category: Uncategorized

Additional information

Membership Type	Life Member, Ordinary Member, Student Member