MEMBERSHIP APPLICATION FORM

KELAB PEMILIK DAN PEMINAT KERETA PROTON

PERSONA MALAYSIA
ROS Registration Number : 2171-08-SEL

Application Type
[ ] New Registration

[ ] Renewal - Membership No:________________

Member Information

Full Name

Identity Card Number

Forum Nick Name
E-Mail Address
Gender
Status
Home Address
City/State
Age
Contact Number
Occupation
Office Address

:
:
:
:
:
:
:
:
:
:
:
:

Car Owner
Car Registration Num.
Year Manufactured
Driving License No
Road Tax Expiry Date
Persona Transmission
Persona Colour

:
:
:
:
:
:
:

_______________________________________
_______________________________________
Your photo
_______________________________________
here
_______________________________________
_______________________________________
[ ] Male
[ ] Female
[ ] Single
[ ] Married
[ ] __________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
(H) ___________ (O) ___________ (HP) ____________
________________________________________________
________________________________________________
________________________________________________
Car Information
[ ] Yes
[ ] No
________________________________________________
________________________________________________
________________________________________________
________________________________________________
[ ] Automatic
[ ] Manual
[ ] Blueberry Tea
[ ] Iridescent White
[ ] Tranquility Black
[ ] Metal Grey
[ ] Light Gold
[ ] Solid White
[ ] Blue Haze
[ ] Brilliant Red
[ ] Solid Red
[ ] Bronze Garnet
[ ] Chiffon Green
[ ] Genetic Silver
Terms and Conditions

1.
2.
3.
4.
5.

Please fill up all the details above as it is a requirement of the ROS.

Please submit membership fee together with this form and get an Official Receipt from our Appointed
Representative.
Fees: One time only ~ RM20.00 ; Annual ~ RM20.00 (Total RM40.00 for new registration)
The committee reserves the right to distribute the information for club use above as it sees fit.
The committee reserves the right to approve/decline membership without giving any reasons.

Signature

Persona Clubs Committee Use:

[ ] Approve

[ ] Rejected

Date: ______________

Person In-charge

_____________________________

Position

Comments

_______________________________________

Membership No.

_______________________________________

________________________

Kelab Pemilik & Peminat Kereta Proton Persona Malaysia

No. 38-2, Jalan SS19/1D, 47500 Subang Jaya, Selangor
Email: membership@thepersonaclub.com

MEMBERSHIP APPLICATION FORM

KELAB PEMILIK DAN PEMINAT KERETA PROTON

PERSONA MALAYSIA
ROS Registration Number : 2171-08-SEL

Name:

Date:

Persona Clubs Committee Use:

[ ] Approve

[ ] Rejected

Date: ______________

Person In-charge

_____________________________

Position

Comments

_______________________________________

Membership No.

_______________________________________

________________________

Kelab Pemilik & Peminat Kereta Proton Persona Malaysia

No. 38-2, Jalan SS19/1D, 47500 Subang Jaya, Selangor
Email: membership@thepersonaclub.com