KOPERASI PEMBANGUNAN EKONOMI INDIA

WILAYAH PERSEKUTUAN BERHAD

(W-4-0928)

APPLICATION FORM FOR INDIVIDUAL MEMBERSHIP

Particulars of Applicant

1. Full Name: MOGGILAVANNAN A/L ARUMUGAM

2. Sex: / Male Female

3. Date of Birth: 0D 7D 0M 1 1 9 8 0 4. Age : 3 7

5. Place of Birth: KUALA LIPIS ,PAHANG

6. NRIC No: 800107-06-5361 (New)

7. Nationality: MALAYSIA _

8. Address: NO.38 LORONG SRI GERISIK _

TAMAN SRI GERISIK ,84800 TANGKAK ,JOHOR.

9. Email Address: moggilavannanarumugam@gmail.com

10. Tel. No: 8. H/P No: 016-5567016

11. Occupation: TEACHER _ _

_
12. Name of Employer/Business: SMK BUKIT GAMBIR ,TANGKAK ,JOHOR
Next of Kin

13. Name : _THENNARASI A/P SABAPATHY

_ _ Relationship: WIFE

14. Tel No. : (H) 0125307016 _ (H/P)

Declaration

15. I hereby apply to enrol as a member of the KOPERASI PEMBANGUNAN EKONOMI INDIA WILAYAH
PERSEKUTUAN BERHAD (W-4-0928), and solemnly pledge to subscribe and abide to Co-operative by laws. I
enclose herewith RM 200.00 (cash only) as a registration fee, for membership which is one-off non-refundable
fee and share investment of RM 150.00 shareholder contribution and a monthly saving of RM 30.00.
Applicant’s Signature Date

A.MOGGILAVANNAN 1.10.2017
………………………………. ……………………………….
Name: MOGGILAVANNAN
IC No: 800107065361
Introducer: _
_
Membership No: __ Introducer Signature
For Office Use Only
Official Receipt No: Membership No: _

Attended By: Approved By: _

(Hon. Secretary)