Pahang membership application

Company Name(Required)

(Company name is name stated in SSM)

SSM Registration Number(Required)

Full Name

Identity Card Number

Gender

Date of Birth

DD slash MM slash YYYY

Etnik

Malay

Bumiputera

Chinese

Indian

Other

Phone

Work Status

Owner

Staff

Volunteer

Membership Category Applied

Ordinary

Associate

Consent Letter(Required)

Accepted file types: pdf, doc, Max. file size: 128 MB.

Download Sample

Are you the Official Representative for the following Premise?

Yes

Centre Name(Required)

(Centre name is name displayed in the centre signboard)

Company Introduction(Required)

Premise Location Address(Required)

Address Line 1 Address Line 2 City ZIP / Postal Code

State(Required)

Category(Required)

Care Centre (PHG)

Nursing Home (Act 586) (PHG)

Others (PHG)

Type(Required)

NGO

Non-NGO

Company Logo

Max. file size: 128 MB.

recommended logo size: 500px by 250px

Name of Person in Charge (PIC)

Gender of PIC

Male

Female

Job Position of PIC

Ownership Type

Sole Propriertorship

Partnership

Body Corporate

Association

Federal Government Agency

State Government Agency

Type of company registration

Suruhanjaya Syarikat Malaysia - SSM (ROC / ROB)

Jabatan Pendaftaran Pertubuhan Malaysia (ROS)

Type of license registration

KKM , Kementerian Kesihatan Malaysia

JKM , Jabatan Kebajikan Masyarakat

Registration in process

Number of Beds

Office Number

Year of operation:

HQ or Branch

Branch

Company Website / FB page (optional)

Is the Premise part of a chain of branches, division or subsidiary to a larger entity?

Yes

a. Identity Card / Passport (if non-citizen) b. Photo of applicant measuring 4.5 cm x 3.5 cm c. Verification of status as Official Representative of premise (if applicable)

Upload Your Identity Card / Passport (for non Malaysian Operators) & Receipt Picture

Drop files here or

Max. file size: 128 MB.

(proof of payment & members can choose to send hard copy to myagecope@gmail.com)

Upload Passport size photo(Required)

Accepted file types: jpg, png, pdf, Max. file size: 128 MB.

Applicant's Name

Full Name

Consent(Required)

I agree all information declared as true, and i agree to always abide to the association constitution.
I hereby understand, my membership application is subject to verification and approval by the association. I further understand that if my application is rejected, my membership will be refunded minus RM1 for administrative fee.

Date

DD slash MM slash YYYY

Enter Code

for those who have already paid, you may enter the special code given here to submit.

Upload receipt(Required)

Max. file size: 128 MB.

First-time Registration - RM125

Renewal - RM100

**Applications rejected will be refunded less RM1.

Association for Residential Aged Care Operators of Malaysia

Membership Registration Pahang

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