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APPLICANT INFORMATION / MAKLUMAT PEMOHON
Name / Nama :
New NRIC No. / No. KP Baru :
Date Of Birth / Tarikh Lahir :
Nationality / Warganegara :
Sex / Jantina :	Male / Lelaki Female / Perempuan
Terms Of Address / Gelaran Kehormat :	Encik / Mr Puan / Mrs Cik / Ms
Marital Status / Status Perkahwinan :	Single / Bujang Married / Kahwin Others / Lain-lain
RACE / BANGSA :	Melayu / Malay Cina / Chinese India / Indian Bumiputra Sabah Bumiputra Sarawak
OCCUPATION / PEKERJAAN :	BEAUTICIAN / JURUSOLEK BUSINESSMAN / PENIAGA EXECUTIVE/SECRETARY / EKSEKUTIF/SETIAUSAHA GRADUATE / GRADUAN HOUSEWIFE / SURI RUMAH LECTURER/TEACHER / PENSYARAH/GURU MANAGER / PENGURUS PROFESSIONAL / PROFESIONAL OTHERS / LAIN-LAIN
POSTAL ADDRESS / ALAMAT SURAT MENYURAT :
HANDPHONE / TELEFON BIMBIT :
Email Address:
SAVING OR CURRENT ACCOUNT NO. / NO. AKAUN :
BANK NAME / NAMA BANK :	CIMB BANK MAYBANK HONG LEONG BANK BERHAD MALAYAN BANK BERHAD PUBLIC BANK
SPOUSE INFORMATION (MARRIED) / MAKLUMAT PASANGAN (KAHWIN)
Name / Nama :
New NRIC No. / No. KP Baru :
Date Of Birth / Tarikh Lahir :
BENEFICIARY INFORMATION / MAKLUMAT PEWARIS
Name / Nama :
New NRIC No. / No. KP Baru :
Relationship / Hubungan :
TO / KEPADA : MELILEA (M) SDN BHD.
AGREEMENT / PERJANJIAN :	I / We wish to apply and become the Distributor of MELILEA (M) SDN BHD with all terms and conditions. / Saya / Kami ingin memohon untuk menjadi Distributor MELILEA (M) SDN BHD. dengan segala terma dan syarat.

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