CPSM Membership Form

Yes! I would like to be a part of Child Passenger Safety Malaysia (CPSM) and pledge to eliminate traffic injuries and death involving children by participating in the coalition through community action, educational interventions, public policy initiatives, and media efforts to advocate for child restraint usage in Malaysia.

Full Name *

First Name Last Name

Current Address *

Street Address

Street Address Line 2

City State

Postal Country

Phone *

Area Code Phone Number

Primary Email *

Organisation / Company Type *

If you are the representative to your organisation, do fill up the organisation name & your position in the organisation.

Organisation / Company Name

Position

Type of Membership *

CPS Ambassador (Coalition Member - RM 599) CPS Technicians (Coalition Member - RM 299) CPSM Friends/Volunteer (Non-Coalition Member - RM 199)

We offer two options for CPS Ambassador Program. Please choose one. *

CPS Talk Child Safety Seat Check Event

CPST ID *

Validity Through *

Date

As a CPSM Friends/Volunteer, you are required to fulfill tasks within the duration of the membership. Please choose in which areas you would like to volunteer doing. (You may choose more than one area). *

Volunteer in at least four (4) of our events Volunteer in writing - contributes to at least 20 web and/or social media contents Volunteer in graphic designing Share at least 40 posts from our Facebook Page onto your timeline or any social media.

CPSM Membership Terms & Conditions *

I understand that acceptance of this application by CPSM does not constitute permission to use the Child Passenger Safety Malaysia logo, name or materials without first receiving approval from CPS Malaysia PLT. CPS Malaysia PLT will not authorize and will not permit any member of the coalition or non-coalition member to authorize any person or organization to use the name and trademarks to promote its products or services for endorsement or other commercial purposes.

Please Sign Here *

CPSM Membership Application Form