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Membership Registration Form
Personal Information
Full Name (as per NRIC)
*
NRIC No.
*
Membership Type
*
New Member
Renewal
Date of Birth
*
Gender
*
Male
Female
Profession
Religion
Language
Residential Address
*
Town
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Postal Code
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State
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Telephone (Work)
Mobile
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Email
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Race
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Malay
Chinese
Indian
Others
Marital Status
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Single
Married
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Primary Beneficiary (for Family Protection Fund)
Name
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Relationship
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NRIC / Passport
*
Mobile
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Allocation
*
Default: 100% or specify other percentage
Declarations
Health Declaration:
I confirm I am between 18-70 years old and do not require medical underwriting.
Source of Funds:
I confirm membership fees are from legitimate sources.
Legal Advice:
I confirm I have received independent legal explanation on this membership's terms.
General Declaration:
I solemnly and sincerely declare that:
I have not been adjudged a bankrupt under the Insolvency Act 1967 (formerly the Bankruptcy Act 1967), and no bankruptcy petition has been filed against me.
I have no criminal record nor have I been charged or convicted in any Court of Law for any criminal offence involving fraud, dishonesty, or moral turpitude.
There is no pending litigation, arbitration, or administrative proceeding that would materially affect my standing or character.
I have made full and true disclosure of all material facts and have not concealed any information that might influence the approval of this application.
Payment Information
Membership Fee:
RM 2,888
Promotion Code (Optional)
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