KELAB USAHAWAN IKHTIAR AMPANG

KUALA LUMPUR & SELANGOR

BORANG KEAHLIAN
GAMBAR

NO.KEAHLIAN:_______________
________
NAMA:_______________________________________________________________________________________
_____________________
NO.KAD
PENGENALAN:_________________________________TEMPAT
LAHIR:________________________________________
ALAMAT
RUMAH:_____________________________________________________________________________________
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______________________________________________________________________________________________
_____________________
NO.TELEFON:
(R)___________________________________________(H/P)___________________________________________
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PUSAT:_____________________________________________BLOK:____________________________________
____________________
PROJEK:______________________________________________________________________________________
____________________
NAMA
PEWARIS:____________________________________________________________________________________
_____________
NO.KAD
PENGENALAN
WARIS:__________________________________________________________________________________
NO.TELEFON
WARIS:______________________________________________________________________________________
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BERSAMA-SAMA INI DISERTAKAN WANG TUNAI BERJUMLAH RM25 UNTUK BAYARAN YURAN
PENDAFTARAN DAN YURAN TAHUNAN.

KELAB USAHAWAN IKHTIAR AMPANG

KUALA LUMPUR & SELANGOR

TANDATANGAN
PEMOHON:____________________________________TARIKH:_______________________________________
_
UNTUK KEGUNAAN KELAB SAHAJA
PERMOHONAN INI DILULUSKAN/TIDAK DILULUSKAN

_____________________________________
__________________________________________
SETIAUSAHA
KELAB USAHAWAN IKHTIAR AMPANG
DITERIMA
KUALA LUMPUR & SELANGOR

BENDAHARI
TARIKH BAYARAN