Membership Application Form – Malaysia Integrative Hypnotherapist Association

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Membership ID

Type of Membership

Select Type of Membership*

Personal Information

Full Name per IC*

Nickname / Shortname*

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

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)*

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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

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Max. file size: 64 MB.

Membership Fee Details

Membership Fee shown as annual fee.

One-Time Registration Fee

Price:

Student Membership

Price:

Associate Membership

Price:

Corporate Membership

Price:

Social Welfare Membership

Price:

Volunteer Membership

Price:

Coupon Code (If Any)

Total Fee

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.