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WEBSITE : http://www.mylivinaclu

MEMBERS$I% &

X MEMBERS$I% &%%LIC&TIO'

Name (as in NRIC/passport) - Please underline surna

X Mr Ms

!m"li#ina!$om ni$%name & YUS

'ter orum ni$%name (i an") & ***************

+ate o ,irt & **** .!0!1.21

(++/MM/YYYY)

Nationalit" & X Mala"sian 'ters ********

3ender & X Male 4emale

Ra$e & X Mala" Cinese

Reli5ion & X Muslim Buddist

Corresponden$e Address & ****6'7 82

****KAMPUN3

***************

Post$ode

7on/Cit"

Conta$t Num,er Mo,ile

=ome

'>$e;-mail address

Nature o or% / desi5nation & ***************

Note & Please t=i$% (?) i$ approriate

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Re5istration No! & **************************

Year Made & **************************

Casis No! & **************************

;n5ine No! & *****************************

Model &X 1!< S7-6 (A/7)

1!< S7-6 (M/7)

1!2 C@7C

@ei$le 'nersip & 'n

B" su,mittin5 tis mem,ersip orm and su,e$ted to app

rules and $onstitution o M" 6i#ina Clu, ereit and old

are not in line it te o,e$ti#es o M" 6i#ina Clu,! I also

eDpress appro#al o te M" 6i#ina Clu, and or/its ele$ted o

sall not ,e eld lia,le in all respe$ts!

Si5nature & ********************************

+ate ********************************

FOR &

Re$ei#ed ," & *********************************

Pa"ment re$ei#ed ," & Cas

Mem,ersip No! & MLC ****

+ (i#clam,"

Su,mission o te appli$ation orm and pa"ment o re5istr

M" 6i#ina Clu, as te ri5t to ree$t an" appli$ation it

te status o teir appli$ation trou5 email/orum/pone

mem,ersip ee sould "our applia$tion ,e!

F 4or ne appli$ation please Elled-up all inormation! In$o

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My Livina Club.com FORM :http://www.mylivinaclub.com/!o"um#

%%LIC&TIO'/RE'EW&L FORM

MEMBERS$I% RE'EW&L

ERSO'&L (ET&ILS

e

'ters Please spe$i" ***************************

USRI BIN ABU BAKAR

NRIC/Passport No! & *** 2!100;G11

********* 'ld I/C No! (i an") & ****************************

Marital status & Sin5le

*********** X Married

+i#or$ed

Indian 'ters ********************************

=indu Cristian 'ters ****************

M 19 :A6AN :I7RA K'+IAN3 ***********************************************

;6;6;

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)E$ICLE (ET&ILS

Color Bla$% X Sil#er

3old 'ran5e

3re" 'ters *****************

Hite

Parent Spouse 'ters *****************

(ECL&R&TIO'

ro#al o m" mem,ersip o M" 6i#ina Clu, I a5ree to ,e ,ound ," te

M" 6i#ina Clu, armless in all respe$ts arisin5 rom m" a$tions i$

a5ree tat an" all a$tions and representations made itout te

>$e ,earers are personal a$tions re-presentation and M" 6i#ina Clu,

******

******

MI'ISTR&TIO' SE O'L*

Appro#ed ," & ******************************************

Ceue Ban%-in

**************************

ation and mem,ersip ees is not proo o a$$eptan$e o mem,ersip!

ut dis$losin5 te reasons tereit! Appli$ant ill ,e dul" notiEed o

itin or 0 ee%s o appli$ation and dul" return te re5istration

mplete orm ill ,e ree$ted! M6C MA/R4 1912 Re# 1

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