Application Form for AOCNA

APPLICATION FORM FOR AOCNA LIFE MEMBERSHIP AND CREDIT CARD PAYMENT

APPLICANT’S INFORMATION

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LIFE MEMBERSHIP

You must select atleast one.


Current appointment/s and institution/s

Primary
Others

You must select atleast one.

Contact Information

Email
Mobile Number
Enter your mobile number with the country code.
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Country code
Enter your office number with the country code (optional).
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Medical Education and Training

Undergraduate Medical education
Postgraduate Medical Education



Paediatric Neurology related training



Other training/ certification (if applicable)



Upload CV *

Note: CV should include minimally A. personal info with photo, B. current appointments/institution, C. past training and professional education, D. research and publications, E. any other information.

Referee (this would preferable be the National Delegate of AOCNA, otherwise an AOCNA member)

Consents


1. Prefix, Name, Appointment, Institution, Specialty/ Subspecialty interests chosen, email

2. e.g. Singapore: Dr Jeremy Lin, Senior Consultant, National University Hospital Singapore, Interests: Cerebral Palsy, epilepsy, email: jeremylin@nus.edu.sg

Agreement Statement for Membership Application to The Asian and Oceanian Child Neurology Association (AOCNA)

1. You consent to sharing your personal and contact information with AOCNA for membership and communication purposes.

2. You authorize AOCNA to contact you regarding AOCNA-related matters, including but not limited to events, updates, and other relevant activities.

3. You agree to abide by the bylaws and constitution of AOCNA, as published on the official AOCNA website.

By proceeding with this application, you confirm that you have read, understood, and accepted the above terms.

PAYMENT METHOD
PayPal
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Total

US $100.00

1 × Life Membership       US$100.00