Pier Goodmann
PARTY SECRETERY
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Membership Application Form
Please fill in the details required and click on Submit.
NAMA PENUH/FULL NAME:
*
GAMBAR MUKA DEPAN BERUKURAN PASSPORT/PASSPORT SIZE FRONT FACE PHOTO.
*
Attach File
No Choosen File
(Max 10 MB)
NO. KAD PENGENALAN/IDENTITY CARD NO:
*
SILA SERTAKAN GAMBAR IC DEPAN/ PLEASE ATTACH YOUR IC (FRONT)
*
Attach File
No Choosen File
(Max 10 MB)
TEMPAT LAHIR/PLACE OF BIRTH:
*
SILA SERTAKAN GAMBAR IC BELAKANG/PLEASE ATTACH YOUR IC (BACK)
*
Attach File
No Choosen File
(Max 10 MB)
BANGSA/RACE:
*
JANTINA/GENDER:
*
Select a Option
LELAKI
PEREMPUAN
TARIKH LAHIR/DATE OF BIRTH:
WARGANEGARA/NATIONALITY:
PEKERJAAN/OCCUPATION:
ALAMAT RUMAH/HOME ADDRESS:
*
ALAMAT KAMPUNG ASAL / HOME VILLAGE ADDRESS
*
TEL. NO.:
*
FAX NO.:
EMAIL:
NAMA KAWASAN PILIHANRAYA/NAME OF CONSITUENCIES:
NEGERI/STATE:
*
Select a Option
N2 – Tasik Biru
N3 – Tanjung Datu
N14 – Batu Kawah
N18 – Serembu
N19 – Mambong
N20 – Tarat
N21 – Tebedu
N22 – Kedup
N23 – Bukit Semuja
N30 – Balai Ringin
N31 – Bukit Begunan
N32 – Simanggang
N33 – Engkilili
N34 – Batang Ai
N36 – Layar
N47 – Pakan
N48 – Meluan
N49 – Ngemah
N50 – Machan
N52 – Dudong
N59 – Tamin
N60 – Kakus
N61 – Pelagus
N62 – Ketibas
N64 – Baleh
N65 – Belaga
N66 – Murum
N68 – Tangong Batu
N69 – Kemena
N70 – Samalaju
N71 – Bekenu
N72 – Lambir
N74 – Pujut
N75 – Senadin
N79 – Bukit Kota
N80 – Batu Danau
PARLIMENT/PARLIMEN:
*
Select a Option
P192 – Mas Gading
P193 – Santubong
P194 – Petra Jaya
P195 – Bandar Kuching
P196 – Stampin
P197 – Kota Samarahan
P198 – Puncak Borneo
P199 – Serian
P200 – Batang Sadong
P201 – Batang Lupar
P202 – Sri Aman
P203 – Lubok Antu
P204 – Betong
P205 – Saratok
P206 – Tanjong Manis
P207 – Igan
P208 – Sarikei
P209 – Julau
P210 – Kanowit
P211 – Lanang
P212 – Sibu
P213 – Mukah
P214 – Selangau
P215 – Mukah
P216 – Hulu Rajang
P217 – Bintulu
P218 – Sibuti
P219 – Miri
P220 – Baram
P221 – Limbang
P222 – Lawas
PENCADANG/PROPOSER:
*
MEMBERSHIP NO./NO KEAHLIAN PENCADANG:
*
PENYOKONG/SECONDER:
Saya memerlukan kad keahlian bercetak / I would like to have printed membership card
Submit
NAMA PENUH / FULL NAME:*
GAMBAR MUKA DEPAN BERUKURAN PASSPORT/PASSPORT SIZE FRONT FACE PHOTO:*
Attach file
No file selected
(Max 10mb)
NO. KAD PENGENALAN / IDENTITY CARD NO:*
SILA SERTAKAN GAMBAR IC DEPAN/ PLEASE ATTACH YOUR IC (FRONT):*
Attach file
No file selected
(Max 10mb)
TEMPAT LAHIR/PLACE OF BIRTH:*
SILA SERTAKAN GAMBAR IC BELAKANG/PLEASE ATTACH YOUR IC (BACK)*
Attach file
No file selected
(Max 10mb)
BANGSA/RACE:*
TARIKH LAHIR/DATE OF BIRTH:*
JANTINA/GENDER:*
Select a option
LELAKI
PEREMPUAN
WARGANEGARA/NATIONALITY:
PEKERJAAN/OCCUPATION:
ALAMAT RUMAH/HOME ADDRESS:*
ALAMAT KAMPUNG ASAL / HOME VILLAGE ADDRESS:*
TEL. NO.:*
FAX. NO.:
Email:
NAMA KAWASAN PILIHANRAYA / NAME OF CONSITUENCIES:
NEGERI/STATE:*
Select a option
N2 - Tasik Biru
N3 - Tanjung Datu
N14 - Batu Kawah
N18 - Serembu
N19 - Mambong
N20 - Tarat
N21 - Tebedu
N22 - Kedup
N23 - Bukit Semuja
N30 - Balai Ringin
N31 - Bukit Begunan
N32 - Simanggang
N33 - Engkilili
N34 - Batang Ai
N36 - Layar
N47 - Pakan
N48 - Meluan
N49 - Ngemah
N50 - Machan
N52 - Dudong
N59 - Tamin
N60 - Kakus
N61 - Pelagus
N62 - Ketibas
N64 - Baleh
N65 - Belaga
N66 - Murum
N68 - Tangong Batu
N69 - Kemena
N70 - Samalaju
N71 - Bekenu
N72 - Lambir
N74 - Pujut
N75 - Senadin
N79 - Bukit Kota
N80 - Batu Danau
PARLIMENT/PARLIMEN:*
Select a option
P192 – Mas Gading
P193 – Santubong
P194 – Petra Jaya
P195 – Bandar Kuching
P196 – Stampin
P197 – Kota Samarahan
P198 – Puncak Borneo
P199 – Serian
P200 – Batang Sadong
P201 – Batang Lupar
P202 – Sri Aman
P203 – Lubok Antu
P204 – Betong
P205 – Saratok
P206 – Tanjong Manis
P207 – Igan
P208 – Sarikei
P209 – Julau
P210 – Kanowit
P211 – Lanang
P212 – Sibu
P213 – Mukah
P214 – Selangau
P215 – Mukah
P216 – Hulu Rajang
P217 – Bintulu
P218 – Sibuti
P219 – Miri
P220 – Baram
P221 – Limbang
P222 – Lawas
PENCADANG/PROPOSER:*
MEMBERSHIP NO./NO KEAHLIAN PENCADANG:*
PENYOKONG/SECONDER:
Saya memerlukan kad keahlian bercetak / I would like to have printed membership card
Submit
X