NAME I/C NO H/P No EMAIL MARRIED STATUS Married Single Divorce HOME ADDRESS Are You Smoker Yes No Nature of work Company Name Annual Income Height Weight In these 5 years have you ever done any blood test Yes No Hospital History Yes No Any family illness history Yes No Nominee name Nominee relationship Parents Spouse Brother/Sister Child Other-Friends Nominee IC no Nominee address Payment Mode Monthly Quaterly Half yearly Yearly Payment Method Debit Card Credit card Bank (Jompay) Car Plate no Bank Name Affin Bank Berhad Affin Islamic Bank Berhad Alliance Bank Malaysia Berhad Alliance Islamic Bank Malaysia Berhad Al Rajhi Banking & Investment Corporation (Malaysia) Berhad AmBank (M) Berhad Bank Islam Malaysia Berhad Bank Kerjasama Rakyat Malaysia Berhad Bank Muamalat Malaysia Berhad Bank of China (Malaysia) Berhad Bank Pertanian Malaysia Berhad (Agrobank) Bank SimpananNasional CIMB Bank Berhad CIMB Islamic Bank Berhad Citibank Berhad Hong Leong Bank Berhad Hong Leong Islamic Bank Berhad HSBC Amanah Malaysia Berhad HSBC Bank Malaysia Berhad Industrial and Commercial Bank of China (Malaysia) Berhad Kuwait Finance House Malayan Banking Berhad MBSB Bank Berhad OCBC Bank (Malaysia) Berhad Public Bank Berhad RHB Bank Berhad RHB Islamic Bank Berhad Standard Chartered Bank Malaysia Berhad Standard Chartered Saadiq Berhad United Overseas Bank (Malaysia) Berhad Bank Account No Bank Account Type Saving account Joint Name account Emergency Contact 1 Emergency Contact Relationship 1 Father Mother Brother Sister Son Daughter Partner - boyfriend / girlfriend friends Relative Emergency Contact 2 Emergency Contact Relationship 2 Father Mother Brother Sister Son Daughter Partner - boyfriend / girlfriend friends Relative Please upload this your IC selfie, ic photo with your sign & ic front and back as the sample show at below. Total 3 photo must upload. Please upload Ic selfie here Premission to store your form information. checking this box indicates your understand and accept that the information you will be store and viewed according to our policy privacy Yes, i undestand and accept my information will be stored. Submit
