ASSYAKIRIN MOSQUE 2D/1N Learning Journey to KL : TV9 Tanyalah Ustaz Programme, Visit to Masjid Imam As Syafie & Institut

Profesional Baitul Mal 30-31 January 2012 $170 (iclusive of transportation, accommodation & food) Name Passport No. NRIC No. Address ) Home/Office tel. LPM/Staff/Pu blic
Passport Expiry Date

D.O.B

Age: S(

Handphone

In Any Case of Emergency, Please call :____________________________Contact:_____________________________________ Relationship:______________________________________

Spouse Particulars Name : Passport No. NRIC No. Children Particulars 1 Name : Passport No. NRIC No. Children Particulars 2 Name Passport No. NRIC No. Others: Name 1 Passport No. NRIC No. Name 2 Passport No. NRIC No. Payment Details Qty Adult Children

Passport Expiry Date D.O.B

Age:

Passport Expiry Date D.O.B

Age:

Passport Expiry Date D.O.B Relationship: Passport Expiry Date D.O.B Relationship: Passport Expiry Date D.O.B Total Amount Paid Receipt No.

Age:

Age:

Age:

SIGNATURE:_______________________ *Pls enclosed amount together with forms. Thank you