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Nationality

Contact Number

Email

Membership Type

Current Occupation / Title

Institution/Organisation/Employer Name

Country of Practice or Study

Specialty/Field of Practice Profession Field of Research/Expertise Current Role Training Program Name Current Field of Study e.g., Nurse, Physiotherapist e.g., AI in Healthcare, Ethics in Technology e.g., AI Developer, Data Scientist e.g., Medicine, Computer Science

Country of Medical Registration Current Affiliation Areas of AI Expertise Institution Educational Institution Name

University, Research Institution

e.g., Machine Learning, Data Privacy

Expected Year of Completion

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Professional Licence or Registration Certificate

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Work ID or letter from Training Institution

Student ID or Letter of Enrolment

Areas of Interest

e.g., AI in Surgery, AI in Diagnostics, Policy Development

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I agree to adhere to ISMAI’s Code of Conduct and Membership Terms.

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