| Membership Form |
Full Name (Capital Letters):.......................................................................................... |
IC Number:.......................................................................................... |
Age:
....................................... Sex:
........................................................ |
Address:
......................................................................................................................
..................................................................................................................................... |
Postal Code:
....................................... Fax:
........................................................ |
Occupation:
.................................................................................................................. |
Telephone(Home):
............................... Telephone(Office):
....................................... |
Email:
................................................................................................................. |
Date:
....................................... Signature:
........................................................ |
| Ordinary Membership............RM 10.00 per annum. |
| Lifetime Membership............RM 100.00 |
| Corporate Membership............RM 500.00 per annum. |
| I hereby enclosed
(Bank Draft/Cheque/Postal Order) amount of RM............... for annual
membership fee / lifetime membership fee. |
| * Cheque payable to: Persatuan Epilepsi Malaysia |
| * Send form and payment to the above address. |
| Office use |
Acceptance date:................................. Receipt no.:...........................
Payment:
.......................................................................................................................
Membership no.:................................. Approval date.:...........................
|
