Contact Information

Title *

SelectDr.Mr.Ms.Others

First Name *

Last Name *

Email ID *

Phone Number

Institution *

Department *

Address *

Country/Region/Territory *

Select oneAustraliaBangladeshCambodiaChinaFijiHongkongIndiaIndonesiaJapanMalaysiaMongoliaMyanmarNepalNew ZealandPakistanPhilippinesSingaporeSouth KoreaSri LankaTaiwanThailandVietnamOthers

Please select your professional position *

SelectDentistGeneral PhysicianHaematologistLaboratory Technologist / ScientistNurse PaediatricianPathologistPhysiatristPhysiotherapistPsychologistOccupational TherapistOrthopaedic SurgeonSocial WorkerOthers

Years of experience in Haemophilia and Allied Bleeding Disorders *

Membership application category *

selectOrdinaryAllied Health ProfessionalAssociate

Details of HTC Physician In-Charge (In case of Allied Health Professionals and Associate Member)

For Allied Health Professionals and Associate Members:

Please upload an official letter certifying that the applicant is employed as an allied health professional in the institution OR is a student, a trainee, or a post-doctoral fellow or/and those with less than 3 years of involvement with haemophilia and allied disorders.

Declaration (Tick the box below) *

I confirm that I am not a full-time employee or service provider of a pharmaceutical company.

Consent *

I agree to register as a Member of AHAD-AP as specified above and have my name listed on the membership roll maintained by AHAD-AP.
I hereby declare that the entries made in this form as above is true and correct to the best of my knowledge and belief.

Date *

Name of applicant *