Membership Application Form

Old Georgians' Association Taiping Online Membership Application
You may apply and pay by Credit Card or Paypal online now. Once we've confirmed your membership and payment, an official receipt will be sent to you.

SUBCRIPTION FEES - Ordinary Member: Entrance RM10.00 & Yearly RM20.00

Life Member: RM200.00 (One time payment)

Cheque/Draft/Money Order/Cash payable to "Old Georgians' Association Taping"

Bank A/c No: 008056404096 (Maybank)

Mailing Address: 47, 1st floor, Jalan Stesen, 34000 Taiping, Perak, MALAYSIA

HP No: +6019 550 3300 (Joseph Lau Tee Sun)
Name*

First NameLast Name
E-mail*
Identity Card No.*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mobile phone*

Area CodePhone Number
Office phone

Area CodePhone Number
Home phone

Area CodePhone Number
Fax No.

Area CodePhone Number
Website
Year in Form 5
Signature
Signature date
MEMBERSHIP TYPE
prevnext( X )
Ordinary Member(30.00MYR for the first year then,20.00MYR for each year)

Life Member(200.00MYR for the first year then, FreeMYR for each year)
Should be Empty:

Old Georgians' Association Taiping Online Membership Application