PERSONAL DETAILS

NAME IC NUMBER
SPOUSE NAME IC NUMBER
MOTHER’S NAME NO. OF DEPENDENTS
MAILING
ADDRESS
COMPANY NAME
COMPANY
ADDRESS
OCCUPATION OFFICE NO.
EPF ACC. NO. MOBILE NO.
EDU LEVEL HOUSE NO.
EMAIL
ANNUAL INCOME Below RM20,000 RM120,001-RM180,000
RM20,001-RM60,000 RM180,001-RM240,000
RM60,001-RM120,000 RM240,001 and above
ESTIMATED NET Below RM50,000 RM500,001-RM1,000,000
WORTH RM50,001-RM100,000 RM1,000,001-RM3,000,000
RM100,001-RM200,000 Above RM3,000,000
RM200,001-RM500,000
EXISTING PLANS:
EPF CASH SAVINGS PLAN INSURANCE/TAKAFUL WASIAT

REMARKS:
1. I AM AWARE THAT I’VE SIGNED 4 EPF FORMS FOR INVESTMENT WITHDRAWAL EVERY 3 MONTHS AS A PART OF THE
PROCESS TO PRACTICE DOLLAR COST AVERAGING. I UNDERSTAND THAT PRACTICING DOLLAR COST AVERAGING
WILL HELP ME MAXIMIZE MY INVESTMENT RETURN.
2. I AM AWARE THAT IF I SIGNED WITH ANOTHER UNIT TRUST COMPANY. IT MAY JEOPARDIZE MY CURRENT INVESTMENT
STRATEGY WITH MY AGENT; MOHD KHAIRUL NIZAM BIN MOHAYAN. THEREFORE, I WILL NOT INVEST WITH OTHER UNIT
TRUST COMPANY UNTIL I COMPLETE THE WHOLE STRATEGIC PROCESS WITH MOHD KHAIRUL NIZAM BIN MOHAYAN
SO THAT I CAN MAXIMIZE MY INVESTMENT RETURN.
3. I AM AWARE THAT THE PURPOSE OF THIS INVESTMENT IS FOR MY RETIREMENT / LEGACY / EDUCATION.

…………………………………………………………………………………
NAME: DATE:

Smoker ___ Non-Smoker Malay Chinese Indian Others:_____________

Muslim Non-Muslim Single Married Widowed Divorced
Male Female Weight (kg):____________ Height (cm): _____________ BMI:
_____________
PAYMENT DETAILS

Auto Debit/Direct Debit Details Credit Card Details (Master/Visa only)

Bank Name : _____________________________ Credit Acc. No. : _____________________________
Bank Acc. No. : _____________________________ Card Expiry Date : _____________________________
Acc. Holder Name : _____________________________ Issued By : _____________________________
NOMINEES

Name : _______________________________ NRIC : _____________________________

Address : ______________________________________________________________________________

NH EMPIRE
Relationship : _______________________________ Occupation: _____________________________
Name of Employer : _______________________________ Type of Business : ________________________
Contact No : _______________________________ Percentage % : ________________________

AGENCY