PERSATUAN BULAN SABIT MERAH MALAYSIA Borang 1

MALAYSIAN RED CRESCENT SOCIETY Cawangan Melaka

Branch
PERMOHONAN MENJADI AHLI
APPLICATION FOR MEMBERSHIP

Permohonan hendaklah dihantar kepada Cawangan yg tersebut di atas dalam dua salinanan dan di sertai dua keping gambar berukuran passport.
This application should be forwarded to above Branch in duplicate with two passport size photographs.

1. Nama penuh ....................................................... ……………………………………………………………………………………………

Name in full (HURUF BESAR / BLOCK CAPITALS)

2. Jawatan / Pangkat ……………………………......................................................………………………………………………………….

Title / Rank

3. Pekerjaan ………………………………………………………………………….....................................................……………………...
Occupation

4. Alamat:
Address
( ) Pejabat ….......………………....................................................…………………………………………………………...
Office
Talipon …………………………….
Telephone

( ) Rumah
………………………………...................................................................................................................................
House
Talipon ………………………………
Telephone

Sila tandakan ( X ) pada alamat surat menyurat.

Please tick correspondence address.

5. Tempat dan Tarikh Lahir ………………………………………………………………………………........................................................

Place and Date of Birth

6. No. Kad Pengenalan …………………………........................................................... Keturunan ....………………………………………

I/C No. Nationality

7. Taraf Kelamin : Kahwin / Bujang ……………………………………………………………………….......................................................

Marital Status : Married / Single

8. Kelulusan Akademik / Iktisas …………………………………………………………………………........................................................

Academic / Professional Qualification

9. Sekiranyer pernah menjadi ahli Persatuan :

If previously a member of the Society :

(a) Jawatan yang dipegang ………………………………..................................... Tahun ...................................

………………………
Position(s) held Year

(b) Tempat Cawangan ………………………....................................................…………………………………………………………

Place Branch

( c ) Kelayakan / Anugerah Bulan Sabit Merah …………………………………………………………...................................................

Red Crescent Qualifications / Award

10.Jawatan yang dipegang dalam lain-lain Persatuan atau Pertubuhan ………………………………….........................................................

Position held in other Society or Organisation
…………..
……………………………………………………………………………………………...............................................................

11. Waris / Penjaga :

Next of Kin :

Nama …………………………………….................................…................... No. Kad Pengenalan ………………………………

Name (HURUF BESAR / BLOCK CAPITAL) I / C No.

Alamat ……………………………………………………………………….....................................................…………………….
Address
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 Talipon ………………………………………................................................. Persaudaraan …………………………………….
Telephone Relationship

12. Minat dalam Kegiatan Persatuan Bulan Sabit Merah.

Interest in Red Crescent activities :

* Perkhidmatan Ambulan /Ambulan Service * Mengutip Derma / Fund Raising

* Pemandu / Driving
* Tugas Bantuan Bencana / Disaster Relief Work
* Melawat Hospital / Hospital Visiting
* Pembantu Klinik / Clinic Assistance
* Pembantu Am / General Assistance
* Jururawat Sukarela / Volunteer Nursing
* Tugas Pentadbiran /Administrative Duties
* Perkeranian / Clerical Work
* Pelawat Rumah /Home Visiting
* Menjahit / Sewing
* Pasukan Bantuan Sukarela Pakaian Seragam
Volunteer Aid Detachment - Uniformed
* Pasukan Belia – Pakaian Seragam
Youth Unit - Uniformed

13. (a) * Ahli seumur hidup – Tidak kurang daripada $1000.00

Life Membership $1000.00
Keahlian terbuka kepada semua dengan bayaran yuran tidak kurang daripada $1000.00 sekali gus
Sijil Ahli seumur hidup akan dikeluarkan.
Open to all with a subscription of $1000.00 payable in a lump sum. A Life Membership Certificate will be issued.

(b) * Ahli Pasukan Bantuan Sukarela / Ahli Biasa - $2.00

Voluntary Aid Detachment / Ordinary Member - $2.00
Ter buka kepada semua orang dewasa dengan bayaran yuran $2.00 diperbaharui pada tiap-tiap 1hb Januari.
Open to all adults with a subscription of $2.00 renewable every 1st January

( c ) * Pasukan Belia – Tidak dikenakan bayaran.

Youth Unit – No Subscription
Terbuka kepada kanak-kanak / belia di peringkat sekolah rendah dan menengah.
Open to all children / youth at primary and secondary school level.

14. Disertakan Ringgit ……………………………. ($ ……………) sebagai yuran dan/senaskah Perlembagaan.

Attached Ringgit as subscription and/ a copy of the Constitution.

Haribulan …………………………… ………….........………………….

Date Tandatangan
Signature
Hantarkan permohonan anda kepada :
Send all application to :

PERINGATAN :
Senaskah Perlembagaan boleh didapati dengan harga $2.00
A copy of the Constitution can be obtained at the price of $2.00

* Potong yang mana tidak berkenaaan

Delete where not applicable

UNTUK KEGUNAAN PEJABAT

FOR OFFICE USE

Permohonan diterima pada …………………………………………………….................................................……………………………………...

Application Received on

Dibentang dimesyuarat pada ……………………………………………………………….......................................... Diluluskan / Ditolak

Tabled at meeting held on Approved / Rejected

Yuran diterima sejumlah …………………………………………………………............ Pada ……...................................……………………...

Subscription Received on

Nombor Resit ……………………………………………………………...................….. Dikeluarkan pada ………........................…………….

Receipt No. Issued on

Nombor Kad Ahli ……………………………………………………………................... Tarikh dikeluarkan ………………...............................

Membership Card No. Date of Issue

Jenis Ahli ………………………………………………………………………………………………................................................……………..

Type of Membership

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…………………………… ……………………………..
Pengerusi Setiausaha
Chairman Secretary

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