KOPERASI PEKERJA-PEKERJA BANK MALAYSIA BERHAD

(KOBANK)
(Registration No. 67)

APPLICATION FOR MEMBERSHIP

(To be filled in BOLD LETTERS)

The Secretary,
Koperasi Perkerja-Perkerja Bank Malaysia Bhd.,
Head Office :
Lot 2-33 & 2-37, 2nd Floor, Kompleks Wilayah.
Jalan Dang Wangi, 50100 Kuala Lumpur, Malaysia.
Tel : 03-26929933 Fax : 03-26927298

I wish to apply for admission as a member of the above Koperasi. The following are my personal particulars:
Name in full : ............................................................................................................................................................................
I.C. No. (New) : ......................................................................................................................................................................
Sex : ................................................................................. Race : ............................................................................................
Date of Birth :................................................................... Occupation : .................................................................................
Marital Status : ................................................................. No. of Children : ..........................................................................
Name of Bank : ........................................................................................................................................................................
Bank Address : .........................................................................................................................................................................
........................................................................................... Post Code : ...................................................................................
Private Address : ......................................................................................................................................................................
........................................................................................... Post Code : ...................................................................................
Tel. No. (Office) ............................................................... Tel. No. (Res.) ..............................................................................
Beneficiary's Name :.................................................................................................................................................................
I.C. No. (New) : ................................................................ Relationship : ...............................................................................
Private Address : ......................................................................................................................................................................
........................................................................................... Post Code : ...................................................................................
Tel. No. (Office) ............................................................... Tel. No. (Res.) .............................................................................

Declaration
I agree to be bound by the Koperasi's By-Laws and to pay a subscription of RM................................................. per month.
I authorise the Koperasi to obtain this amount by deduction each month from my salary or account. I hereby state that i am
not a member of any lending cooperative.

I enclosed cheque/Banker's cheque No. ............................... For RM ..............................being payment of the following:-

a) Entrance Fee RM 5.00

b) Subscription RM
Total RM

Date : .................................................. ......................................................................

Signature of Applicant

The Board of Management of Koperasi Pekerja Pekerja Bank Malaysia Berhad reserves the right to accept or reject any
application for membership without assigning any reason.