Membership Application Form
Type of Membership:
Annual Subscription Fee:
I would like to help in the running of THASUH activities.
I am Mr.Mrs.EncikPuanDato'DatukDatinTan SriPuan SriTun
the fathermotherguardian of patient named
UHRN: currently on treatment for thalassaemia at University Hospital.
I will pay by: chequemoney orderpostal order no:
of amount RM for membership application.
(Please send payment to THASUH at the above address)