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Permohonan Keahlian

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Pendaftaran *
Nama *

First Name Last Name
No. K/P *

Alamat Rumah

Street Address
Street Address Line 2
City	State
Zip Code	Country

Displin *
Jawatan
Gred

Alamat Pejabat

Street Address
Street Address Line 2
City	State
Zip Code	Country

E-mel Rasmi *
E-mel Peribadi *
example@example.com
No. Tel. Pejabat

- Area Code Phone Number
No. Tel. Bimbit *

- Area Code Phone Number
Jenis Keahlian *
Yuran:

Pendaftaran: RM 30.00 (Sekali bayaran sahaja)

Ahli Seumur Hidup: RM 100.00 (Sekali bayaran sahaja)

Ahli Biasa: RM 30.00 (Diperbahrui setiap tahun)

Maklumat Bank

Nama Bank: MAYBANK

Nama Akaun: PERTUBUHAN PROFESIONAL JKR MALAYSIA

No. Akaun: 5643 4260 2041
Bukti Bayaran *
Transaksi dalam talian/Mesin Deposit
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Signature

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