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- This form shall be completed by registed member
- You shall complete all information followed by your personal information and entries. Use "Reset"
button to reset form entries. Use "Submit" button to proceed membership registration process.
- All fields are required to be filled before submitting this form.


A. APPLICANT
Name:
I/C No:
Passport No:
Date of Birth:
Sex: Male:   Female:  
Nationality:
Race:
Marital Status: Single:   Married:  
Your Address :
Tel:
Fax:
H/P no:
Email:
  You are
Diver –PADI
Diver – NAUI
Non –Diver
  Level
Open Water Diver
Advance open Water
Rescue Diver
Dive Master
Instructor
 
B. DECLARATION


I hereby apply to become a member of Malaysian Coral Reef Conservation Society (CoRal Malaysia)) and I certify that the foregoing information is true and complete and fully realize that omission or falsification of information will be considered sufficient reason for rejection of this application or for subsequent dismissal.

I would like to apply for:

Yearly membership – RM 30 (Ringgit Malaysia Thirty Only)

and agree that if I should submit this form my signature will be treated as if
it was my original signature written in pen.

Your Signature: