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Registration Form
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PROGRAM INFORMATION
Program Membership No
The Program Membership No field is required.
Identification No
The Identification No field is required.
empty
LOGIN INFORMATION
User Name
The User Name field is required.
Password
The Password field is required.
Confirm Password
The Confirm Password field is required.
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GENERAL INFORMATION
Member Name
The Member Name field is required.
Identification Type
The Identification Type field is required.
Identification No.
The Identification No field is required.
Please enter without '-' or space, i.e. 580306025010
Email
Mobile No.
Gender
The Gender field is required.
 
Date of Birth
The Date of Birth field is required.
Age
Nationality
The Nationality field is required.
empty
Address 1
Address 2
City
Postcode
State
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NEXT OF KIN INFORMATION
Name
Relationship
Contact No.
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BANK ACCOUNT INFORMATION
Bank Name
The Bank Name field is required.
Bank Beneficiary Name
The Bank Beneficiary Name field is required.
Bank Account No.
The Bank Account No field is required.
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SECONDARY MEMBER(S)
No. Relationship Name Status Action
No data available in table
{{ index + 1 }} {{ getRelationshipName(secondaryMember.secondary_member_relationship) }} {{ secondaryMember.name }} {{ getStatusName(secondaryMember.status) }}
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MEMBERSHIP GUIDELINE
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The Agree to terms and conditions field is required.
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