Application Form /

Borang Permohonan

New Application / Permohonan Baru Renewal / Pembaharuan

Personal Details / Butir-butir Peribadi

Full name (As in IC/Passport) / Nama Penuh (seperti dalam KP/Pasport)

Mr/Encik Mrs/Puan Miss/Cik Others/Lain-lain

_____________________________________________________________

Old IC No. / Passport No. / No. KP Lama / No. Passport

New IC No. / No. KP Baru

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Date Of Birth (DD/MM/YY) / Tarikh Lahir (HH/BB/T T)

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Race / Keturunan

_____________________________

Marital status / Status perkahwinan

Single / Bujang Married / Berkahwin

Gender / Jantina
Male / Lelaki Female / Perempuan

Mailing Address / Alamat Surat Menyurat

_____________________________________________________________

_____________________________________________________________

_______________________________________ Postcode ______________

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Home Telephone No. / No. Telefon Rumah

Occupation / Pekerjaan

_________________________________________

Office Telephone No. / No. Telefon Pejabat

Mobile Phone No. / No. Telefon Bimbit

E-mail Address / Alamat E-mail

_________________________________________

Name to appear on card (not more than 20 characters) /

Nama pada kad (tidak lebih 20 abjad)

Next of kin (for Personal Accident Insurance purpose) /

Saudara terdekat (untuk tujuan Insuran Kemalangan Peribadi)

________________________________________________________

Vehicle’s Details / Butir-butir Kenderaan

Vehicle Model / Model Kenderaan

_________________________________________

Vehicle Registration No. / No. Pendaftaran Kenderaan

_____________________________________

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By signing this form, the applicant hereby acknowledge the rules and
regulations laid in KAPMA's constitution and agree to abide by them/
Dengan menandatangani borang ini, pemohon dengan ini menerima syarat-syarat
dan peraturan yang tertera dalam perlembagaan KAPMA dan bersetuju untuk
mematuhinya.

_____________________ ____________________
Signature of Applicant/ Dealer's Stamp/
Tandatangan Pemohon Cop Pengedar

FOR KAPMA's USE ONLY / UNTUK KEGUNAAN KAPMA SAHAJA

Tarikh Diterima : _____________________

No. Resit : _____________________

No. Keahlian : _____________________

Diluluskan Oleh : _____________________

Disemak Oleh : _____________________

Tarikh Kad Dikeluarkan : _____________________

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Membership Fee / Yuran Keahlian

Registration Fee / Yuran Penyertaan : RM10

Annual Fee / Yuran Tahunan : RM50
Total / Jumlah : RM60

Payment Method

Cash
• Cash and KAPMA form must be submitted to the nearest Perodua outlets only.

Direct Debit into KAPMA Account

• Payment can be made direct to KAPMA Account No: 1233-0001263-05-3 (Bumiputra
Commerce Bank (M) Berhad).
• For this method of payment, please submit the KAPMA form together with the 'bank-in-slip'
as proof of payment.

Personal Cheque
• Cheque must be crossed and made payable to 'Kelab Automotif Perodua Malaysia'.
• For outstation cheque, please include RM0.50 for bank commission.
• Submit the cheque together with the KAPMA form.

Money Order / Postal Order / Bank Draft

• For this method of payment, please make payable to 'Kelab Automotif Perodua Malaysia'.
• Submit the payment together with the KAPMA form.

Credit Card
• Credit card facilities can be obtained from Perodua Service Centres only.
• Fulfill the KAPMA form and visit our nearest Perodua Service Centres to make the payment.
• Submit the invoice together with the KAPMA form.

Mailing Address
KELAB AUTOMOTIF PERODUA MALAYSIA
c/o Perodua Automotive Centre
Sungai Choh, Locked Bag No.226
48009 Rawang,
Selangor Darul Ehsan

Tel: 03-6092 8888

Fax: 03-6733 0289
kapma@perodua.com.my

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