Sabah Kidney Society

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Membership Form

(Print and fill  a copy of the form and send the form to the society through fax: 088-211664 or to the Sabah Kidney Society at No. 822, Taman Dah Yeh Villa, Jalan Damai,  
88400, Kota Kinabalu
Sabah, Malaysia Tel: 088-219901)

(Please submit a copy of your passport size photograph)

 I wish to become an individual/Institution Member of the Persatuan Buah Pinggang Sabah.

Name: _____________________________________I.C/Passport No: _________________

Date of Birth : _____________    Gender : Male/Female        Marital Status: Married/Single

Citizenship: _______________  Occupation: _______________________

Full Postal Address: _____________________________________________________

                                _____________________________________________________
 

Telephone No (Office) : _______________________   Telephone No(Home): _____________

My remittance in the sum of RM ___________is enclosed being subscription for the year _______. (Ordinary individual members RM10.00 per annum. Ordinary institution members RM200.00 per annum)
 
 
 
 
 
 

Date: ____________________ Signature: _____________________
Proposed by: ____________________ Seconded by: __________________
Name & Membership No: ___________ 

________________________________

Name & Membership No: __________ 

_______________________________

----------------------------------------------------------------------------------------------

(OFFICIAL USE ONLY)

Date Receipt Sent :

Receipt No:                           Membership Card No:

Sent on:

Signature:


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