User Membership Application

Lembaga Estetika Medik - CBAM Authorized Centre in Jakarta, Indonesia

"*" indicates required fields

Select Your occupation: *

Title

First Name*

Last Name

Job Title / Occupation

Designation

Email *

Street Address*

Address Line 2

City*

Province

Postal Code

Country

Date of Birth *

Phone *

Fax

Are you a clinic owner? *

Are you currently enrolled as student in Medical school, Nursing, or Dentistry? *

Do you have experience working in the field of Aesthetic Medicine?*

Designation

Please type here your exact name with the title combination you wish to appear on your certificate(s). (The capitalization of the titles before and after your name will be manually corrected and then added to your records.)*

This name and title will be reflected on all your CBAM certificates. Please ensure this is correctly spelled. Examples of combinations:

Dr. Alyssa Maryam

Dr. Alyssa Maryam, MD

Alyssa Maryam MD

Please upload a document(s) in support of your Medical License, Nursing License, Medical Esthetician diploma, Professional license/certification, or your student card or business card (in case of being in aesthetic business)*

Choose File

If your document is not in English or French, please provide a certified translation along with the picture of the original document. Please note that aesthetic certificates from other educational institutions are not acceptable.

Upload more document (if applicable)

Choose File