Application for MIPMM Membership



Name of Company:

Company Number:

Year of Incorporation:

Registered Address:

Postcode:

Telephone:

Tele Fax:

Email Address:

Country:

Company Web Site:


Is Your Company HRDF Registered?

   Yes        No

Nature of Business:

   Sole Proprietorship
   Partnership
   Sendirian Berhad
   Association
   Co-operatives
   Social Enterprise
   Government

Business Environment:

   Manufacturing
   Service
   Consulting
   Government
   Academic


Industry Type of Your Division:

   Automotive
   Food/Beverages
   Communication
   Furniture
   Distribution
   Glass
   Education
   Graphic Arts
   Electrical
   Retail
   Healthcare
   Maintenance/Repair
   Metal Fabrication
   Lumber/Paper
   Pharm/Chemical
   Software
   Plastics/Rubber
   Utilities
   Textile/Apparel



Industry Classification of Your Division:

   Jobshop
   Assembly
   Process
   Non-Manufacturing
   Remanufacturing
   Discrete


Description of Business Activities:


Number of Employees in Organization (Tick One):

   Under 100
   100 - 249
   250 - 499
   500 - 999
   1000+

Appointed Representative

Please register the following representative for Company Membership


Name:

Job Title(Appointed Representative):

Citizenship:

Sex:

   Male       Female

Appointed Representative Email:

IC No (New):

Date Of Birth:

IC No (Old):

Home Address:

Correspondent Address:

Telephone:


Approving Managers Name:

Job Title (Approving Manager):

Date:

Email (Approving Manager):


Membership Fees (Free for 2 years : 1st Jan 2016 to 31st Dec-2017)



Entrance Fees:

Annual Subscription:


YES! I Wish to Join MIPMM for :

   ONE Year       TWO Years      THREE Years

Amount Payable:

(Entrance Fees + Annual Subscription ) x (No of Years)= Amount Payable


*(Please provide the amount below)


Complete

You have successfully completed all steps.


   I hereby certify that all information supplied in this application for membership is true and correct