NAME (as per I/C)

NRIC No.

SEX

HOME ADDRESS

OFFICE ADDRESS

MAILING ADDRESS

OCCUPATION

YEAR LEFT SCHOOL

TEL (HOUSE)

TEL (OFFICE)

H/PHONE

FAX

I WISH TO APPLY AS A/AN ______________________ MEMBER AND ABIDE BY THE CONSTITUTION OF THE SEKOLAH MENENGAH SULTAN ABDUL SAMAD EX-STUDENTS ASSOCIATION. I ENCLOSED HEREWITH MY CHEQUE/MONEY/POSTAL ORDER NO.:__________________ FOR THE SUM OF RM____________ BEING PAYMENT FOR MY MEMBERSHIP FEE. (PAYMENT IS TO BE MADE PAYABLE TO "PERSATUAN MURID-MURID TUA SEKOLAH MENENGAH SULTAN ABDUL SAMAD") ____________________ APPLICANT'S SIGNATURE ____________________ DATE ____________________ PROPOSER (Membership No..............................) ____________________ SECONDER (Membership No..............................)

MEMBERSHIP FEES

LIFE MEMBER ORDINARY MEMBER ASSOCIATE MEMBER for school's present & ex-staff only) RM 500.00 RM 30.00 per annum RM 15.00 per annum

TYPE OF MEMBERSHIP		MEMBERSHIP NO.
AMOUNT RECEIVED		RECEIPT NO.
APPLICATION APPROVED BY		SIGN __________________ ON