Name/Surname:

IC No.: Place/Date of Birth:

Home Address:

Tel (H):

Occupation: Tel (O):

Company /Organization:

Race/Origin: Chinese Muslim Others if you select others, please identify others:

Date of Embraced Islam: Marital Status: Married Bachelor Divorced Widower/widowee Single Mother

Academic/Educational Background:

Language: English Mandarin BM Arabic Others

I wish to register as MACMA Member : Organisation Individual and submit a fee by : Cheque Bankdraft Postal Order (AC Payee Only) as Below: RM10/1 year RM20/3 years RM50/9 years

(Note: Attach your Business Card and Self/family photograph for our publication if agreeable. New Member will receive 2 edition of MACMA Bulletin annually.

Signature: ____________________________________ Date:

Thank you!