Application For Membership

Mental Illness Awareness & Support Association

Persatuan Kesedaran dan Sokongan Penyakit Mental

(PPM-027-10-14072017)

6, Lorong 16/9A, Seksyen 16, 46350 Petaling Jaya, Selangor.

Helpline: +603-7932 1409 | Email: info.miasa@gmail.com

Application For Membership

APPLICATION FOR MEMBERSHIP

I wish to apply for Membershjp with your Association and I undertake to observe the Rules and Constitution of the Association. I am a Malaysian Citizen and over 18 years old and my personal particulars are as follows: -

Name

Gender

Male

Female

NRIC No.

Age

Date of Birth

Place of Birth

Correspondent Address

Tel No.

Fax

Profession/Occupation

Are you a peer (a person with a mental health disorder)?

Yes

Please state your diagnosis

I wish to offer my service as follows (if relevant):

Fees : Please tick whichever is applicable and forward the remittance with your application

Full Member – RM 50 (Subscription - yearly)

Life Member – RM 1000 (One-time payment)

Full Member - RM 50 (Subscription - yearly)

Fee: RM50.00

Life Member - RM 1000 (One-time payment)

Fee: RM1,000.00

Application For Membership

Mental Illness Awareness & Support Association

Persatuan Kesedaran dan Sokongan Penyakit Mental

APPLICATION FOR MEMBERSHIP

Crisis Helpline: 1800 180 066

Crisis Whatsapp: 03-9765 6088