| 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:...........................
|
