Master Eload Registration Form

MASTER ELOAD MEMBER REGISTRATION FORM

* compulsory to be filled

Member Particulars

Name/Company Name *

:

Date of Birth

:

Gender

:

Male Female

IC No/Passport No *

:

eg: 790101145001

Race

:

Address

:

Postcode

:

City

:

State

:

Occupation

:

Contact Details

Dedicated H/Phone No *

:

eg: 0121234567

Telephone

:

eg: 032271888

Fax

:

eg: 032272888

Email

:

eg: xxx@xxx.com

Sponsor H/Phone No

:

eg: 0121234567

Bank in Details

Bank In Date *

:

eg: 15/07/2007

Bank In Time*

:

eg: 03:20PM

Bank*

:

eg: Maybank

Bank In Amount*

:

eg: RM100.00