borang pendaftaran rapidkl / rapidkl registration form · 2017-12-27 · - - tandatangan /...

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- - Tandatangan / Signature

No. Kakitangan/Staff ID No.

Tertakluk kepada Terma-Terma dan Syarat-syarat / Terms and Conditions Apply.Potong disini/ Cut here

Keratan Pemohon Pendaftaran RapidKL / RapidKL Registration Applicant Slip

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Tandatangan / Signature

Untuk Kegunaan RapidKL / For RapidKL Use :

No Siri Kad / Card Serial No.

MyRapid

Tarikh Pungutan / Collection Date :

OKU / DisabledWarga Emas /

Senior CitizenPelajar / Student

Kampus / Campus :

Tarikh Pengaktifan / Activation Date :

Encik / Puan / Cik :

Mr / Ms :

Kerakyatan Negara

: Nationality: Warga Asing. Sila nyatakan. Foreign citizen. Please state.

Jumlah bayaran : Total Payment :

Emel / Email :

Permohonan Telah Disahkan Oleh :

Application Form Verified By :

RM:

No Telefon / Telephone No.

No Tel. Bimbit / H.phone No.

Warga Emas / Senior Citizen

Malaysia

No Siri Kad / Card

Serial No.

Jumlah bayaran :Total Payment :

RM :

OKU / Disabled Pelajar Sekolah Rendah / Menengah

No. Pasport / Passport No:

Tarikh Pengaktifan / Activation Date :

Tarikh Pungutan / Collection Date :

Pelajar Kolej / Universiti

OKU / Disabled

Warga Emas / Senior Citizen

Pelajar Sekolah Rendah / Menengah

Pelajar Universiti / Kolej

No. Pasport / Passport No.

No. KP / I/C No.

Tarikh Lahir / Date of Birth :

Encik / Puan / Cik :

Mr / Ms :

No. Kad Pelajar / Student Card

Sekolah / Kolej / Universiti :

School / College / University :

Borang Pendaftaran RAPIDKL / RAPIDKL Registration Form

Pembaharuan / Renewal

Butir Peribadi Saya / My Personal Details (Sila isi yang berkenaan / Please fill in where applicable)

Gantian / Replacement

Produk MyRapid Konsesi

No. Kad JKM / JKM Card No.

Baru / New

No. KP / I/C No.