Persatuan Sejarah Malaysia

Cawangan/Kawasan.........................................................
Alamat : ..........................................................................
.........................................................................................
.........................................................................................
Tel : ................................. Faks : ..................................

Di isi oleh
cawangan &
kawasan
masing-masing

_____________________________________________________________________________________
Saya ingin memohon untuk menjadi ahli PERSATUAN SEJARAH MALAYSIA sebagai:
a. Ahli Biasa RM15.00

b. Ahli Seumur Hidup RM300.00*

c. Ahli Institusi RM50.00

d. Ahli Gabungan RM100.00

e. Ahli Penuntut RM10.00

(Sila tandakan x dalam kotak yang berkenaan)
Yuran pendaftaran ahli kategori a-d: RM10.00, kategori e: RM5.00
1.Nama penuh (Huruf Besar): ..........................................................................................................................
(Tan Sri/Puan Sri/Dato/Datin/Tuan/Puan)
2.No. Kad Pengenalan Baru : ................................................... K.P.Lama : ..................................................
3.Tarikh lahir ........................................................... Tempat lahir ..................................................................
4.Pekerjaan : .............................................................................................................. (sekarang)
Jika bersara : .......................................................................................................(pekerjaan dahulu)
5.Alamat rumah ...............................................................................................................................................
.................................................................................................................... Poskod : ...................................
Tel. : .............................................. H/P: .........................................................
Faks : ............................................. E-mel : ....................................................
6.Alamat pejabat : ............................................................................................................................................
.......................................................................................................................Poskod : ..................................
Tel. : .............................................. H/P: .........................................................
Faks : ............................................. E-mel : ....................................................
7.

Jawatan dalam badan amal yang sedang dan pernah dipegang :

.....................................................................................................................................................
......................................................................................................................................................

.......................................................................................................................................................
8.

Penulisan yang pernah diterbitkan :

........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................

Bersama-sama ini disertakan Cek/Kiriman Wang Pos No. : .................................................../Wang

Tunai** berjumlah RM ................................ ( termasuk RM10.00 bagi wang pendaftaran ahli kategori a-d
atau

RM5.00

bagi

c)

atas

nama

PERSATUAN

SEJARAH

MALAYSIA

CAWANGAN/KAWASAN............................................................................... untuk bayaran menjadi ahli

yang berkenaan.
(** Potong mana yang tidak berkaitan)
* Yuran Ahli Seumur Hidup boleh dibayar sekali gus atau secara ansuran dengan membayar
pendahuluan sebanyak RM50.00+RM10.00 (wang pendaftaran) dan bakinya dibayar dengan cek
post dated bernilai RM50.00 setiap cek. Taraf Ahli Seumur Hidup hanya sah selepas bayaran
kelima dilunaskan, sementara itu taraf keahlian adalah sebagai Ahli Biasa.
Disertakan dua (2) keping gambar warna berukuran gambar pasport.
Pencadang : ...................................................................................... No. ahli : ...............................................
Tandatangan : ..............................................................
Alamat : ............................................................................................................................................................
...........................................................................................................................................................................
Tel.

...............................................

H/P

...............................................

Faks : ....................................................
Penyokong : .................................................................................... No. ahli : .................................................
Tandatangan : ..............................................................
Alamat : ............................................................................................................................................................
...........................................................................................................................................................................
Tel.

...............................................

H/P

...............................................

Faks : ....................................................
...................................................................

................................................

Tandatangan Pemohon

Tarikh

UNTUK KEGUNAAN PEJABAT

Tarikh di terima :
Keahlian diterima pada :
No. ahli :