Application Access Card FORM

DAnjung Teluk Pulai Security Scheme- Purchasing Car Sticker And Motorcycle sticker Item
DAnjung Teluk Pulai Car & Motorcycle Sticker Damage or Lost

Cost
RM 5.00 Per Sticker RM 10.00 Per Sticker

Please fill in the details below: How many Sticker you would like to Purchase Sticker

NAME 1. 2. 3. 4. 5. 6. 7.

ADDRESS

SERIAL NO:

Note: 1. Each Name Application must be enclosed with photocopy NRIC. Strictly for Purchasing Resident and their family members living in the same house ONLY. DAnjung Teluk Pulai Car and Motorcycle sticker is for the usage of DAnjung Teluk Pulai residence only. The access will be revoked if found there is misuse of these items. I, undersign hereby enclose Cheque Cash for amount of RM..............................Made payable to "Persatuan Penduduk D'Anjung Teluk Pula Klang" being the purchase of DAnjung Teluk Pulai Sticker. Name: (.) IC NO: (.) Date: (//12.) Approved by . Date:/./12..