Membership Application Form

Personal Information

Name

First Name

Last Name

Gender

Male

Female

Date of Birth

Email

Contact No.

Phone

Practice Information

PRC License No.

PRC License Expiry Date

Clinic Address

Type of Practice

Private - General Practice

Private - Specialist

Government

Other…

Enter other…

Education and Training

Institution of Undergraduate Degree

Periodontal Graduate / Specialty Training Institution

Training Complete Year

Application Requirements

I am applying as an

Active Member

Associate Member

Upload the following documents in one (1) PDF file:

Upload

1. Letter of Intent
2. Comprehensive bio-data/ curriculum vitae
3. Academic and training certifications and other pertinent certifications
4. Updated copy of PRC license
5. PDA Certificate of Good Standing (COGS)

Upload requirements

• One file only.
• 512 MB limit.

What PSP member benefit do you look forward to the most and why?

Agreement

I certify that the foregoing information is true and correct to the best of my knowledge. I believe I am eligible for membership in the category requested.

I agree to advise the Society of any changes in the status that would amend or alter the information provided in the application.

I understand that a portion of the membership fee is payment for the membership to the European Federation of Periodontology.

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