Persatuan Epilepsi Malaysia / Malaysian Society of Epilepsy Jabatan Neurologi Hospital Kuala Lumpur 50586 Kuala Lumpur Malaysia Tel: 03 - 2615 5405

Borang Permohonan

Nama Penuh (Huruf Besar):..........................................................................................

No. K/P:..........................................................................................

Umur: .......................................   Jantina: ........................................................

Alamat: ...................................................................................................................... .....................................................................................................................................

Poskod: .......................................   Faks: ........................................................

Pekerjaan: ..................................................................................................................

Telefon(Rumah): ...............................   Telefon(Pejabat): .......................................

E-mel: .................................................................................................................

Tarikh: .......................................   Tandatangan: ........................................................

Ahli Biasa............RM 10.00 setahun.

Ahli Seumur Hidup............RM 100.00

Ahli Korporat............RM 500.00 setahun.

Saya sertakan wang pos/cek/draf bernilai RM............... sebagai yuran tahunan/seumur hidup.

* Cek dibayar kepada: Persatuan Epilepsi Malaysia

* Borang dan pembayaran boleh dihantar ke alamt di atas.

Untuk kegunaan pejabat

Tarikh diterima:................................. No. Resit:........................... Bayaran: ....................................................................................................................... No. Ahli:................................. Tarikh diluluskan:...........................