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Usm Alumni Association Membership Form: Personal Details

This document is a membership form for the USM Alumni Association. It requests personal details like name, citizenship, gender, address, phone number, and qualifications from USM. It also asks for employment details and includes payment information, noting a fee of RM100 for life membership registration or RM5 to upgrade an alumni card. Applicants are to attach a money order, cheque, or cash payment to the completed form and signature before submitting it to the USM Alumni Association secretariat office for processing.

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Shahrir Ray
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65 views1 page

Usm Alumni Association Membership Form: Personal Details

This document is a membership form for the USM Alumni Association. It requests personal details like name, citizenship, gender, address, phone number, and qualifications from USM. It also asks for employment details and includes payment information, noting a fee of RM100 for life membership registration or RM5 to upgrade an alumni card. Applicants are to attach a money order, cheque, or cash payment to the completed form and signature before submitting it to the USM Alumni Association secretariat office for processing.

Uploaded by

Shahrir Ray
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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USM ALUMNI ASSOCIATION MEMBERSHIP FORM

PERSONAL DETAILS
NAME :
CITIZENSHIP : Malaysian Others (please specify)
IC NUMBER : GENDER : Female Male
ADDRESS (home) :
POSTCODE : TOWN : STATE :
PHONE (home) :
EMAIL 1 :
EMAIL 2 :
HANDPHONE :

EMPLOYMENT DETAILS
COMPANY :
POSITION/JOB TITLE :
ADDRESS :
POSTCODE : TOWN : STATE :
PHONE (office) : FAX NUMBER :

QUALIFICATION(S) DETAILS
Graduate Course School Year Graduate
Diploma
Degree
Master
PhD
*Qualifications from USM only.
I, hereby attach a money order/cheque (number : )/cash amounting to
RM payable to PERSATUAN ALUMNI UNIVERSITI SAINS MALAYSIA.

*Fee also can be transfer to Persatuan Alumni USM CIMB Account (86-0094662-3). Please
attach the payment receipt together with this form.

For : Life membership registration (RM100 only) For Secretariat use only
Upgrade Alumni Card (RM 5.00 only) Received by :
USM Alumni contribution Membership Number :
Signature : Membership card : Printed
Posted
Date :

Pejabat Sekretariat, Persatuan Alumni USM, Bangunan D12, Universiti Sains Malaysia, 11800 Minden, Pulau Pinang.
Tel : 04-653 2166/04-656 9370 Fax: 04-656 9370 Email : [email protected] Laman Web : www.ausm.com.my

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