Online Member Registration
Member's Particulars
1 **  Name
2 Occupation
3 Date of Birth Pick a Date
4 Place of Birth
5 Race
6 Race Specify
7 Citizenship
8 Citizenship Specify
9 **  Document Type
10 Document Type Specify
11 **  Identification Number (e.g MyKad Number / Old IC Number)
12 Qualification
13 Board Registration Number
Address of Employer
1 Address
2 Postcode
3 Town
4 State
Home Address
1 Same as above
2 Address
3 Postcode
4 Town
5 State
Postal Address
1 Same as above
2 **  Address
3 **  Postcode
4 **  Town
5 **  State
Contact
1 #  Tel. No (Home)
2 #  Tel. No (Office)
3 #  Handphone No.
4 **  Email
Payment / Subscription Details
Membership Info
Please Bank in to the following account :
Account Name : PERSATUAN PEMBANTU PERUBATAN DAN JURURAWAT DIALISIS MALAYSIA
Bank : CIMB Bank
Account No : 80-0050987-7
1 **  Member Start Year
2 **  Description / Amount
3 **  Payment Method
4 Bank
5 Cheque No. / Bank Ref No.
6 Money / Postal Order No.
7 Upload Payment Slip
(pdf, jpg, jpeg, png only)
Upload Certificate (pdf, jpg, jpeg, png only)
1 **  Diploma
2 Basic Certificate
3 APC
4 Others
Login Details
1 **  Login Name
2 **  Login Password
3 **  Verify Password
  Image Verification
Change Image
4 **  Type the characters you see in this image :