University of the Third Age, KL & Selangor

MEMBERSHIP REGISTRATION FORM . Borang Pendaftaran Keahlian

Please complete the following for record-keeping purposes:

Sila lengkapkan butiran berkenaan untuk simpanan rekod:

1. Personal Details . Butiran Peribadi

Name . Nama

IC No. . No. K/P

Title . Gelaran Tun / Tan Sri / Pn. Sri / Dato’ / Datin / Prof. / Dr. / Mr. / Mrs. / Ms.

Date of Birth . Tarikh lahir

Sex . Jantina Male . Lelaki Female . Perempuan

Ethnicity . Keturunan Malay . Melayu

Chinese . Cina

Indian . India

Other Bumiputera . Bumiputera Lain

Others . Lain-lain

Education . Pendidikan No formal education Tiada pendidikan formal

Primary education Pendidikan sekolah rendah

Secondary education Pendidikan sekolah menengah

Tertiary education Pendidikan kolej / universiti

2. Contact Information . Maklumat Perhubungan

Mailing Address . Alamat Surat-menyurat

City / State . Bdr./ Negeri Postcode . Poskod

Hp. No. . No. Tel. Bimbit Tel. No. . No. Tel.

Fax No. . No. Faks E-mail . E-mel

3. Emergency Contact Number . Nombor Hubungan Kecemasan

Name . Nama

Relationship . Hubungan

Hp. No. . No. Tel. Bimbit Tel. No. . No. Tel.

4. Association’s Corresponding Address . Alamat Surat-menyurat Persatuan

Tel. : 603-89472755 / 2741 . Fax : 603-89472744 / 2738 . E-mail: u3aklsel@gmail.com

K L & S E L A N G O R

Association for Lifelong Learning of Older Persons (U3A) Kuala Lumpur and Selangor

Persatuan Pembelajaran Sepanjang Hayat Warga Emas (U3A) Kuala Lumpur dan Selangor c/o Institute of Gerontology . Institut Gerontologi Universiti Putra Malaysia 43400 UPM Serdang, Selangor, Malaysia

5. Payment Instructions . Arahan Pembayaran Please forward the form with payment, a photocopy of your identity card and two (2) passport-sized photos to U3A Kuala Lumpur & Selangor.

Sila hantar borang ini berserta bayaran, salinan kad pengenalan dan dua (2) keping gambar bersaiz pasport kepada U3A Kuala Lumpur & Selangor.

All banker’s order / banker’s cheque should be made payable to “U3A KL & Selangor”.

Segala bayaran cek harus dibuat di atas nama “U3A KL & Selangor”.

FOR OFFICE USE . Untuk Kegunaan Pejabat

Membership No. No. Keahlian

Payment Details Butiran Pembayaran

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Member Category & Fees Kategori Ahli & Yuran

Ordinary Member . Ahli Biasa (55+) [RM25 per year . setahun]

Life Member . Ahli Seumur Hidup (55+) [RM150 one-time payment . sekali seumur hidup]

Associate Member . Ahli Bersekutu (50-54) [RM25 per year . setahun]

Note: A one-time member registration fee of RM10 is applicable for new members only.

Nota: Yuran pendaftaran / masuk sebanyak RM10 dikenakan sekali ke atas ahli-ahli baru sahaja.

U3AKLSelangor/MemberF/290311/v.1.01/CST