Association for Haemophilia and Allied Disorders - Asia Pacific Membership Application Form

Contact Information

Title *

Select Dr. Mr. Ms. Others

First Name *

Last Name *

Email ID *

Phone Number

Institution *

City/Town *

Address *

Country/Region/Territory *

Select one Australia Bangladesh Cambodia China Fiji Hongkong India Indonesia Japan Laos Malaysia Mongolia Myanmar Nepal New Zealand Pakistan Philippines Singapore South Korea Sri Lanka Taiwan Thailand Vietnam Others

Please select your professional position *

Select Dentist Nurse Pathologist Physiatrist Physiotherapist Psychologist Occupational Therapist Orthopaedic Surgeon Social Worker Laboratory Technologist/Technician Laboratory Scientist Physician/Paediatrician/Haematologist Others

Years of experience in Haemophilia and Allied Bleeding Disorders *

Membership application category *

Ordinary Allied Health Professional Associate

Details of HTC Physician In-Charge (In case of Allied Health Professionals and Associate Member)

For Allied Health Professionals and Associate Members*:

Kindly provide an official letter from the HTC Incharge certifying that the applicant meet both of the following criteria:
a. The applicant is employed as an allied health professional in the institution and
b. Is actively involved in the care of haemophilia and allied bleeding disorders.
OR
a. The applicant is a student, trainee, post-doctoral fellow, or has less than three years of experience in the field of haemophilia and related disorders and
b. Is actively involved in the care of haemophilia and allied bleeding disorders.

Note: .pdf,.doc,.docx,.JPEG,.PNG,.jpg formats only

Declaration (Tick the box below) *

I confirm that I am not a full-time employee or service provider of a pharmaceutical company.

Consent *

I agree to register as a Member of AHAD-AP as specified above and have my name listed on the membership roll maintained by AHAD-AP.
I hereby declare that the entries made in this form as above is true and correct to the best of my knowledge and belief.

Date *

Name of applicant *