Membership Application Form – Malaysia Integrative Hypnotherapist Association

Type of Membership

Select Type of Membership*

Student Member

Associate Member

Corporate Member

Social Welfare Member

Volunteer Member

Personal Information

Full Name per IC*

Preferred Name*

Prefix Preferred Name Surname

Date of Birth*

IC / ID No.*

Gender*

Phone Number*

Email*

Nationality*

Address*

Street Address Address Line 2 City State / Province / Region Postcode Country

Qualification Information

Kindly select your modality in mental health industry.

Select one or more

Hypnotherapy

Psychotherapy

Counselling

Psychology

Art Therapy

Child Therapy

Speech Therapy

Cognitive Behavioural Therapy

Other

Other Modality

Hypnotherapy / Psychotherapy Qualification Studies

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Date of Graduation (dd/mm/yyyy)

Name of Institution / Academy

Name of Program / Course

National / International Accreditation Body

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Date of Accreditation (dd/mm/yyyy)

Name of Accreditation Body / Association

Name of Professional Title

Academic Qualification

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Year of Graduation

Name of College / University

Major Studies

Other Professional Program Attended (If Any)

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Course Name

Duration

Name of Institution / Academy

Profession

Document Checklist

Kindly upload your documents for verification purpose.

IC / National ID Copy (Front and Back)*

Drop files here or

Max. file size: 64 MB.

Passport Size Photo / Formal Photo

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Max. file size: 64 MB.

Highest Education Qualification and Certification

SPM, Diploma, Degree, Master or Phd

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Max. file size: 64 MB.

Letter of Admission / Offer Letter

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Max. file size: 64 MB.

National or International Certificate in field of Mental Health

Hypnotherapy, Psychotherapy, Psychology or other relevant certification

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Max. file size: 64 MB.

Company SSM Superform

Drop files here or

Max. file size: 64 MB.

Once your membership application is approved, you will be guided to make payment via email instruction.

Membership Agreement

Agreement*

- I hereby confirmed and agreed that all information that I provided are absolutely accurate and correct.
- As being a MIHA members, I also agreed to comply with included but not limited to MIHA's Code of Ethic, Code of Discipline, Guidelines, Policies and Membership Handbook.

Yes, I Agree.

Signature*

Full Name per IC*

IC No.*

Date of Submission

Name

This field is for validation purposes and should be left unchanged.