KOPERASI VISAKHA KULIM KEDAH BERHAD

(K-4-0385)

I wish to apply for admission as a member of the Koperasi Visakha Kulim Kedah Berhad My personal particulars are as follows :(1) FULLNAME : OLD I/C NO : (4) GENDER: (6) AGE : MALE YRS FEMALE

(2) NEW IDENTITY : CARD NO (3) DATE OF BIRTH (5) PLACE OF BIRTH (7) ADDRESS : : :

POSTCODE: CITY: (8) MARITAL : STATUS MARRIED NOT MARRIED STATE: (09) NO. TEL ( Home ) (10) NO. HANDPHONE COUNTRY: : :

(11) IF MARRIED ( Please mention name of SPOUSE ) (i) NAME : OLD I/C NO : Referral

(ii) NEW IDENTITY : CARD NO DECLARATION BY APPLICANT

I ___________________________________________________
Hereby declare that if admitted as a member of the Co-Operative Society, I will abide By-Laws and rules of the Co-Operative Society and any amendments made to those by-laws and rules . I hereby certify that I am not a bankrupt or a person against whom a conviction stands for a registrable offence and that I have not been expelled from membership of any Co-Operative Society during the previous one year period. __________________ ________________________

DATE
Enclosed herewith Cheque /Postal Order for RM Shares And RM for entrance fees. of which RM

Signature of Applicant
is for

Note : - Each member is required to pay a minimum of RM 300.00 towards shares and RM 10.00 As entrance fees . X members are required pay RM 50.00 as entrance fees.

** Attached 1 Copy of Photostat(front & back ) Identity Card ( I/C ) No.24 , Jalan Kempas 1 , Taman Kempas Indah 2, 09000 Kulim kedah Darul Aman Tel : +604-491 0653/4 Fax : 04-491 0652

KOPERASI VISAKHA KULIM KEDAH BERHAD

(K-4-0385)

NOMINATION
I wish to nominate the following person/s as my nominee/s upon my death:No 1 2 3 4 5 Name of nominee Identity Card No Percentage Relationship

FOR OFFICE USE Ref No Date Approved : :

Payment Received: Date Received :

No.24 , Jalan Kempas 1 , Taman Kempas Indah 2, 09000 Kulim kedah Darul Aman Tel : +604-491 0653/4 Fax : 04-491 0652