PART A

Personal Details

Full Name

Gender

Date of Birth

Nationality

Contact Details

Postal Address

City

Postcode/Zip

Mobile Number Select your Country & Enter Mobile Number

Email

Country

Job Title/Designation

PART B

QUALIFICATIONS AND TRAINING

Primary Qualification

Date Awarded

Name of Awarding Institution/College

Country

Names of other Examinations & Dates Passed

Please confirm the route taken to gain your additional qualifications

PART C | For Membership without examination (Fill only if applicable)

NON EXAMINATION ROUTE ONLY

Provide names and ID numbers of your sponsors plus provide evidence of your clinical experience to demonstrate the level of clinical expertise you have attained (Total 200 words):

PART D

Declaration

Declaration:
I hereby declare that the information provided above is true to the best of my knowledge. I also understand that falsifying information is ground for refusing my registration. I acknowledge that the membership programs are skill enhancement continuing educational initiatives and may not be recognised by my respective state/country for registration purpose. So, their misuse as Master’s Degree Qualifications or anything similar could be punishable as per my state laws. The academy promotes membership purely to boost the scientific knowledge of its members with the sole intention of helping the society and patients with updated care. However, the academy has no legal privity of contract with any of its members and thus cannot be held responsible for any untoward incidences arising out of any member's acts of negligence/malpratice/falsification of information etc. All legal matters subject to academy respresentative's native / local / home-town jurisdiction only.

If my registration is accepted, I do solemnly and sincerely declare that I shall be a faithful member of this academy, obey all the laws, regulations and bye-laws made, and to be made in future and shall do nothing which in the opinion of the academy is prejudicial to the interest of, or derogatory to, the honour of the academy or of my profession. The academy is occasionally asked by employers, government bodies or similar organisations to verify an individual’s membership/qualification status for employment purposes. I consent to Asian Academy of Laser Therapy providing verification of my membership status to 3rd parties.

Please note: IF YOUR CANDIDATURE IS SELECTED, THE FEES PAID is NON-REFUNDABLE.

HOWEVER, THE ACADEMY RESERVES THE RIGHT TO REJECT YOUR APPLICATION WITHOUT STATING ANY REASON AND IN SUCH CASES YOU WILL BE ISSUED 100 % REFUND.