The Peranakan Association Application for Life Membership

Name Select Title Prof. Dr. Mr. Mrs. Ms.

NRIC Nationality Date of Birth (ddmmyy) Sex Male Female

Home Address
Postal Code

Tel (H) Hp Pg Fax

Email

Office Address
Postal Code Tel (O) Fax (O)
Email

Marital Status Married Single Divorced (if married) Name of spouse

Occupation

Are you a Peranakan? Yes No

(If yes) Are you a Peranakan on maternal side paternal side both

Applicant's Signature ______________________ Date ______________________

Proposer Membership No. Signature __________________

Seconder Membership No. Signature __________________

For Official Use Only

Membership No. __________________ Date of Approval __________________

Receipt No. _______________ Bank ___________ Cheque No. ______________

Honorary Secretary ____________________________________