CLIENT SIGN UP FORM
AIA PUBLIC TAKAFUL
Full Name / Nama Penuh
*
as per ID / seperti Kad Pengenalan
Last Name
ID Number / Kad Pengenalan
*
With “-“ symbol / beserta “-“ simbol
Type a question
Male / Lelaki
Female / Perempuan
Phone Number / Nombor Telefon
*
With “-“ symbol / beserta “-“ simbol
Date of birth / Tarikh Lahir
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email / Emel
*
example@example.com
Home Address / Alamat Rumah
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Religion / Agama
Race / Bangsa
Marital Status / Status Perkahwinan
Single / Bujang
Married / Berkahwin
Divorced / Bercerai
Dependent & Children / Tanggungan
Name of Employer / Nama Syarikat Bekerja
(Jika suri rumah , tulis nama pasangan )
Office Address / Alamat Pejabat
Street Address ( Jika suri rumah , tulis alamat rumah )
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation / Pekerjaan
Monthly Income / Pendapatan Bulanan (RM)
*
Have you had any operation or had any illness,disease or disorder / Pernah melakukan pembedahan atau mempunyai penyakit yang sudah sedia ada?
*
Yes / Ya
No / Tidak
If yes declared here / Jika ya , nyatakan disini
Height / Tinggi (cm)
Weight / Berat (kg)
Nominate / Waris ( max 4 orang )
*
Bank Account Details / Butir Bank Akaun
*
ID Card / Kad Pengenalan (Front / Depan )
ID Card / Kad Pengenalan (Back / Belakang)
Debit or Credit Card ( Front Only ) / Debit atau Kredit Kad ( Depan Shj)
Signature
*
Submit
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