ICCP Membership Registration Revised Form

ICCP Membership Registration Form
Head of Family name - Nama Kepala Keluarga (optional)
Surname or Parent's Family name
Required membership registration as stated in article 8-21 of the ICCP constitution
Full Name*
Family status*

Husband (Suami)Wife (Isteri)Single Adult (Dewasa single, umur diatas 18 tahun)Other
List of dependants below 18 years old and DOB (optional)
Dependant names can be filled on separate paper form off-line if necessary
Address*
Street Name
Suburb*
Postcode*
Number only
Wilayah (Refer to list of suburbs belonging to which 'ICCP wilayah')

St. PeterSt. BenedictSt. MarySt. John & St. PaulSt. Thomas More
Mobile Phone*

Country CodePhone Number
Email (optional)
example@example.com
Status of Residence*

Australian Citizen or Permanent / Tempororary ResidentStudent VisaOther
DOB (optional)

DayMonthYear
Tanggal lahir
Date of Marriage (optional)

DayMonthYear
Date
Like to serve in : (optional)

Liturgy (Lector, Choir, Altar Minister, Catechist)TransportationEquipment (sound system)ConsumptionPublication (Photography, Video, Newsletter, Article Writing)Children LiturgyOther
Do you wish to receive messages and notifications sent by ICCP?

YesNo
Kami menjamin kerahasiaan informasi diatas dan hanya digunakan untuk intern ICCP, tidak untuk dipublikasikan atau untuk tujuan komersial apapun.

If you agree to provide your details, please click submit. If you don't, then cancel and skip this form.
Remarks - only to be filled in by Membership Team member
Name

First NameLast Name
                                                        Wilayah-wilayah ICCP

St. Peter                  = Semua suburb yang berada di North of the River.

St. Benedict            = Alfred Cove, Applecross, Ardross, Attadale, Bicton,    Booragoon, Brentwood, Melville, Mt. Pleasant, Rossmoyne, Shelley.

St. Mary                  = Belmont, Bentley, Cannington, East-Cannington, Como, East Victoria Park, Ferndale,       Gooseberry Hill, Harvey, Kensington, Manning, Rivervale, South Perth, St. James, Victoria Park, Waterford, Wilson.

St. John & St. Paul = Atwell, Aubin Grove, Banyup, Bull Creek, Canning Vale, Gosnells, Harrisdale, Huntingdale, Jandakot, Kenwick, Leeming, Maddington, Lynwood, Park Wood, Piara Waters, Queens Park, Southern River, Thornlie, Willeton.

St. Thomas More     = Semua suburb yang berada di sebelah selatan Leach Highway, dari Fremantle sampai Kwinana Freeway (a.l.: Beeliar, Bateman, Bibra Lake, Cockburn, Kardinya, Murdoch, South Lake, Success, Willagee, Winthrop, Yangebup). Daerah selatan meliputi Rockingham dan Mandurah.
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ICCP Membership Registration Form