Name (as per Identification Card or Passport)*
Please type your full name.
Nationality*
Malaysian Afghan Albanian Algerian American Andorran Angolan Antiguans Argentinean Armenian Australian Austrian Azerbaijani Bahamian Bahraini Bangladeshi Barbadian Barbudans Batswana Belarusian Belgian Belizean Beninese Bhutanese Bolivian Bosnian Brazilian British Bruneian Bulgarian Burkinabe Burmese Burundian Cambodian Cameroonian Canadian Cape Verdean Central African Chadian Chilean Chinese Colombian Comoran Congolese Congolese Costa Rican Croatian Cuban Cypriot Czech Danish Djibouti Dominican Dominican Dutch East Timorese Ecuadorean Egyptian Emirian Equatorial Guinean Eritrean Estonian Ethiopian Fijian Filipino Finnish French Gabonese Gambian Georgian German Ghanaian Greek Grenadian Guatemalan Guinea-Bissauan Guinean Guyanese Haitian Herzegovinian Honduran Hungarian I-Kiribati Icelander Indian Indonesian Iranian Iraqi Irish Irish Israeli Italian Ivorian Jamaican Japanese Jordanian Kazakhstani Kenyan Kittian and Nevisian Kuwaiti Kyrgyz Laotian Latvian Lebanese Liberian Libyan Liechtensteiner Lithuanian Luxembourger Macedonian Malagasy Malawian Malaysian Maldivan Malian Maltese Marshallese Mauritanian Mauritian Mexican Micronesian Moldovan Monacan Mongolian Moroccan Mosotho Motswana Mozambican Namibian Nauruan Nepalese Netherlander New Zealander Ni-Vanuatu Nicaraguan Nigerian Nigerien North Korean Northern Irish Norwegian Omani Pakistani Palauan Panamanian Papua New Guinean Paraguayan Peruvian Polish Portuguese Qatari Romanian Russian Rwandan Saint Lucian Salvadoran Samoan San Marinese Sao Tomean Saudi Scottish Senegalese Serbian Seychellois Sierra Leonean Singaporean Slovakian Slovenian Solomon Islander Somali South African South Korean Spanish Sri Lankan Sudanese Surinamer Swazi Swedish Swiss Syrian Taiwanese Tajik Tanzanian Thai Togolese Tongan Trinidadian or Tobagonian Tunisian Turkish Tuvaluan Ugandan Ukrainian Uruguayan Uzbekistani Venezuelan Vietnamese Welsh Yemenite Zambian Zimbabwean Invalid Input
Identification Card No.*
Invalid Input
Passport No.*
Invalid Input
Issuing Country*
Please Select Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling Islands) Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire (Ivory Coast) Croatia (Hrvatska Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea (North) Korea (South) Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovak Republic Slovenia Solomon Islands Somalia South Africa S. Georgia and S. Sandwich Isls. Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States US Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Viet Nam Virgin Islands (British) Virgin Islands (US) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe Invalid Input
Date of Issue*
Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Month 01 02 03 04 05 06 07 08 09 10 11 12 / Year 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 Invalid Input
Date of Expiry*
Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Month 01 02 03 04 05 06 07 08 09 10 11 12 / Year 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 Invalid Input
Gender*
Female Male Please specify your position in the company
Date of Birth*
Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Month 01 02 03 04 05 06 07 08 09 10 11 12 / Year 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 Invalid Input
Ethnicity*
Malay Chinese India Others Invalid Input
As required by the Ministry of Health Malaysia (Kementerian Kesihatan Malaysia)
Other ethnic groups:*
Invalid Input
Home Phone No.
Invalid Input
Mobile Phone No.*
Invalid Input
Office Phone No.
Invalid Input
Working Address*
Invalid Input
Correspondence Address*
Invalid Input
Practice Experience*
Years 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Please select number of years. Choose 1 for experience less than a year or none.
Please select number of years. Choose 1 for experience less than a year or none
Type of Membership*
Regular Membership (refer to ACM By-Law Section 6.1.1) Non-Practicing Membership (refer to ACM By-Law Section 6.1.3) Please specify your Type of Membership
Membership Period*
01 January to 31 December 01 July to 31 December Please specify your Membership Period
PRIMARY CHIROPRACTIC QUALIFICATION
Chiropractic Programme Attended*
Invalid Input
Qualification*
Please type your Primary Chiropractic Qualification
Duration of Study*
Years 0 1 2 3 4 5 6 7 8 9 10 Invalid Input
Date of Graduation*
Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Month 01 02 03 04 05 06 07 08 09 10 11 12 / Year 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 Invalid Input
OTHER CHIROPRACTIC QUALIFICATION
Institution Name
Invalid Input
Qualification
Please type other Qualification
Duration of Study
Years 0 1 2 3 4 5 6 7 8 9 10 Invalid Input
Date of Graduation
Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Month 01 02 03 04 05 06 07 08 09 10 11 12 / Year 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 Invalid Input
PRIOR PRACTICE EXPERIENCE*
Yes No Invalid Input
CHIROPRACTIC LICENSURE
Country*
Malaysia ------------ PLEASE SELECT OTHER COUNTRY ------------ Afghanistan Akrotiri and Dhekelia Aland Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Ascension Island Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central Africa Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'lvoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon Cambia, The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guemsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, N Korea, S Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Cyprus Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcaim Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Sahrawi Arab Democratic Republic Saint-Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and Grenadines Samos San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Togo Tokelau Tonga Transnistria Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Yemen Zambia Zimbabwe Invalid Input
State*
PLEASE SELECT A STATE ------------ Wilayah Persekutuan Johor Kedah Kelantan Malacca Negeri Sembilan Pahang Perak Perlis Penang Sabah Sarawak Selangor Terengganu Invalid Input
State*
------------ PLEASE SELECT A STATE ------------ Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Invalid Input
Registration No.
Invalid Input
Registration No.*
Invalid Input
Date of Registered*
Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Month 01 02 03 04 05 06 07 08 09 10 11 12 / Year 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 Invalid Input
Country
Malaysia ------------ PLEASE SELECT OTHER COUNTRY ------------ Afghanistan Akrotiri and Dhekelia Aland Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Ascension Island Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central Africa Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'lvoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon Cambia, The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guemsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, N Korea, S Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Cyprus Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcaim Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Sahrawi Arab Democratic Republic Saint-Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and Grenadines Samos San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Togo Tokelau Tonga Transnistria Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Yemen Zambia Zimbabwe Invalid Input
State
PLEASE SELECT A STATE ------------ Wilayah Persekutuan Johor Kedah Kelantan Malacca Negeri Sembilan Pahang Perak Perlis Penang Sabah Sarawak Selangor Terengganu Invalid Input
State
------------ PLEASE SELECT A STATE ------------ Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Invalid Input
Date of Registered
Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Month 01 02 03 04 05 06 07 08 09 10 11 12 / Year 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 Invalid Input
Country
Malaysia ------------ PLEASE SELECT OTHER COUNTRY ------------ Afghanistan Akrotiri and Dhekelia Aland Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Ascension Island Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central Africa Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'lvoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon Cambia, The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guemsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, N Korea, S Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Cyprus Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcaim Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Sahrawi Arab Democratic Republic Saint-Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and Grenadines Samos San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Togo Tokelau Tonga Transnistria Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Yemen Zambia Zimbabwe Invalid Input
State
PLEASE SELECT A STATE ------------ Wilayah Persekutuan Johor Kedah Kelantan Malacca Negeri Sembilan Pahang Perak Perlis Penang Sabah Sarawak Selangor Terengganu Invalid Input
State
------------ PLEASE SELECT A STATE ------------ Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Invalid Input
Registration No.
Invalid Input
Date of Registered
Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Month 01 02 03 04 05 06 07 08 09 10 11 12 / Year 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 Invalid Input
PREVIOUS CHIROPRACTIC PRACTICE(S)
Country / State
PLEASE SELECT A STATE ------------ Wilayah Persekutuan Johor Kedah Kelantan Malacca Negeri Sembilan Pahang Perak Perlis Penang Sabah Sarawak Selangor Terengganu ------------ PLEASE SELECT A COUNTRY ------------ Afghanistan Akrotiri and Dhekelia Aland Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Ascension Island Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central Africa Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'lvoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon Cambia, The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guemsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, N Korea, S Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Cyprus Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcaim Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Sahrawi Arab Democratic Republic Saint-Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and Grenadines Samos San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Togo Tokelau Tonga Transnistria Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Yemen Zambia Zimbabwe Invalid Input
Company Name
Please type other Qualification
Period of Practice
Years 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 / Months 01 02 03 04 05 06 07 08 09 10 11 12 Please select number of years and months
Please select number of years and months
Country / State
PLEASE SELECT A STATE ------------ Wilayah Persekutuan Johor Kedah Kelantan Malacca Negeri Sembilan Pahang Perak Perlis Penang Sabah Sarawak Selangor Terengganu ------------ PLEASE SELECT A COUNTRY ------------ Afghanistan Akrotiri and Dhekelia Aland Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Ascension Island Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central Africa Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'lvoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon Cambia, The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guemsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, N Korea, S Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Cyprus Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcaim Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Sahrawi Arab Democratic Republic Saint-Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and Grenadines Samos San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Togo Tokelau Tonga Transnistria Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Yemen Zambia Zimbabwe Invalid Input
Company Name
Please type other Qualification
Period of Practice
Years 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 / Months 01 02 03 04 05 06 07 08 09 10 11 12 Please select number of years and months
Please select number of years and months
Country / State
PLEASE SELECT A STATE ------------ Wilayah Persekutuan Johor Kedah Kelantan Malacca Negeri Sembilan Pahang Perak Perlis Penang Sabah Sarawak Selangor Terengganu ------------ PLEASE SELECT A COUNTRY ------------ Afghanistan Akrotiri and Dhekelia Aland Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Ascension Island Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central Africa Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'lvoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon Cambia, The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guemsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, N Korea, S Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Cyprus Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcaim Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Sahrawi Arab Democratic Republic Saint-Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and Grenadines Samos San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Togo Tokelau Tonga Transnistria Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Yemen Zambia Zimbabwe Invalid Input
Company Name
Please type other Qualification
Period of Practice
Years 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 / Months 01 02 03 04 05 06 07 08 09 10 11 12 Please select number of years and months
Please select number of years and months
Are you practicing chiropractic at the moment?*
Yes No Invalid Input
CURRENT CHIROPRACTIC PRACTICE
CCP Company Name
Please type other Qualification
Date of Commencement
Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Month 01 02 03 04 05 06 07 08 09 10 11 12 / Year 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 Invalid Input
Practice Name & Address
Invalid Input
Do you provide after-hours / emergency care at your clinic?*
Yes No Please specify if you provide after-hours / emergency care at your clinic
Do you provide house visits?*
Yes No Please specify you you provide house visits
Are you covered by Professional Indemnity Insurance?*
Yes No Invalid Input
Please specify the period, insurance company and attach a copy of the policy
Insurance Company*
Invalid Input
Beginning*
Expiring*
Upload copy of the policy (PDF)*
Invalid Input
Do you wish to buy Professional Indemnity Insurance coverage from MSIG?*
Yes No Invalid Input
ACM will send our agent to contact you to purchase your Professional Indemnity Insurance as soon as possible
Please note your membership will not be processed without a Professional Indemnity Insurance
Have you ever been disciplined by any professional association and / or licensing body?*
Yes No Invalid Input
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Certified true copy of chiropractic certificate*
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Certificated true copy of chiropractic license certificate
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Letter of good standing
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How would you like to pay your member fee?*
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Please transfer/bank in your membership fee to
Bank : CIMB
Account number : 8002360559
Account Name : Persatuan Kiropraktik Malaysia
Please include the following in the transaction slip
1. Amount of deposit (RM)
2. Date of deposit
3. Beneficiary account number
4. Cheque number (only for cheque deposit)
5. Cheque Issuing Bank (only for cheque deposit)
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Mobile Phone No.
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DECLARATION BY APPLICANT
I hereby apply for membership into the Association of Chiropractic Malaysia and agree to abide by the rules, bylaws, regulations, Code of Ethics, and Advertising guidelines adopted by the Association.
I agree to uphold the principles of the Association, to assist in all ways to accomplish the Association’s objectives, and to pay and be liable for all dues and professional indemnity insurance premiums imposed by the Association in accordance with the Rules.
I hereby declare that all the information that I have provided with this application is true. I understand that any misrepresentation of the information provided whether wilful or unintentional may result in my immediate dismissal from the Association of Chiropractic Malaysia and a formal report with recommendations to be made to relevant regulatory bodies.
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