Persatuan Bekas Putera

The Old Putera Association

APPLICATION FORM FOR MEMBERSHIP
To be filled and returned to
“THE OLD PUTERA ASSOCIATION
Penthouse, Bangunan OPA, Saujana Resort, Seksyen U2, 40150 Shah Alam”

NAME IN FULL : ........................................................................................................................ I.C. NO: ……………………...…

(please underline surname)
HOUSE ADDRESS: ................................................................................................……………….............................................……….
.......................................................................................................................................................................................... ............................

TEL. NO: .....................….…………... H/P NO: ....……..........…............... E-MAIL: ........…………..…………..................................

ORGANIZATION : ………………………………………………………………………………………………………………………

OFFICE ADDRESS: ........................................................................................…..........………………..…….….....……………..……

Please underline address .........……………….......................……......................………….……………................................................
for correspondence TEL. NO: .............…………..….... FAX NO: .......…….….......…........ E-MAIL: ........…………..…................

PROFESSION/ OCCUPATION: …………….............................… RANK/APPOINTMENT: ...........................................................

DETAILS WHILE IN BOYS COMPANY/WING FMC/RMC;

Year In : ………………………… Year Out : …………………….
Form In : ……………………...... Form Out : …………………....
Rank : …………………………... Company : ………………..........
Regt No: ........................................ Date of Birth: .................................

SCHOOL OF ORIGIN: .................................................................…………........…................………………………......………….......

NAME OF WIFE: ..................................................................................................………………........…………………………….…....
OTHER INFO : ..................................................................................................………………........…………………… ……….…........

* Please enrol me as a LIFE MEMBER. Enclosed my cheque no…………………….... for RM530/- being full payment for the fee.
* Please enrol me as a LIFE MEMBER. Enclosed my cheque no…………………….... for RM106/- being my initial payment for the
fee. I shall pay the balance RM424.00 in 4 consecutive monthly instalments of RM106/ each.
* Please enrol me as a ORDINARY MEMBER. Enclosed my cheque no…………………….... for RM106/- being payment of
Entrance fee (RM53/-) and annual subscription (RM53/-) for the year.
**Payment include Gst (6%)

NOTE : i. *Please delete where not applicable. Signature : ........................………………...

ii. All Cheques are to be made payable to
“THE OLD PUTERA ASSOCIATION”. Date : ……………………………...………
“or Bank-in to our Account : CIMB – 8600595996”

FOR OFFICIAL USE ONLY

Date Received : ……………………………………..………. Received By: ……………………………….……………….….

Membership No : ……………………………………………. Official Receipt No : ………………….……….……………….
Membership Card Issued :…………………………………. Secretary : ………………………………..…………………….
Cheque No./ Cash : ………………………………………… Treasurer : ………………………………..…………………….