ORG/MBR/Form1a/V1.

SGM MEMBER RECORD FORM

SGM 会 员 表 格

Organisation Details (Place of Activity) 活动所属组织:

State Zone Region Chapter District Block

州 圈 区 支部 地区 班

English Name Chinese Name

英文姓名 中文姓名
I/C No. (New) /
Passport No. Date of Birth
身份证号码 (新) / 出生日期
护照号码
Nationality Marital Status
国籍 婚姻状况

Division Date Started

Practising
部别
入信日期
Member Family Member Gohonzon Recipient
Member Type
会员 家族会员 御
会员类别
本尊敬领者

(Unit/House No.) __________________ Telephone No.

电话号码
(Building/Garden/Street) ___________

Home Address ________________________________ Mobile Phone No.

住址 手机号码
________________________________

(City) ___________________________ Email Address

电邮
Postcode: State:
Introducer Mobile Phone No.
介绍者 手机号码
Remarks
备注

Note: For teenagers and children below 18, parents’/guardian’s consent is needed.
注意事项：18 岁以下的青少年与儿童，必须获得家长/监护人认同。

I, hereby, give my consent to Persatuan Soka Gakkai Malaysia (SGM) to collect, analyse and use my personal data as
Persatuan Soka Gakkai Malaysia (SGM) deems fit and Persatuan Soka Gakkai Malaysia (SGM) shall not use such data provided
by me for any commercial purposes. I shall abide by the Constitution of SGM, the Rules and Regulations of SGM and any bye-laws
made pursuant to the Constitution of SGM.
在此，我作出许可，马来西亚创价学会可收集、分析和使用我的个人资料于创价学会认为适当的用途。我将遵守马来西亚
创价学会的章程、会规和所有根据章程规定的规则。

Signature of Applicant 申请者签署 : _______________________________ Date 日期 : _________________

Chapter PIC’s Signature of

Date
Name Chapter PIC
日期
支部负责者姓名 支部负责者签署