No. 15, Jalan SS3/6, 47300 Petalig Jaya, Selangor Darul Ehsan.

Tel/Fax : 603 - 7875 7808E-mail: budiscop@gmail.comWebsite: www.mbcs.org.my

KOPERASI BUDDHISME MALAYSIA BERHAD (MALAYSIAN BUDDHIST CO-OPERATIVE SOCIETY LIMITED)

(PLEASE USE CAPITAL LETTERS) 1. Name (as per NRIC) :_____________________________________________________________

2. NRIC no. :_____________________________________________________________

3. Date of Birth :_____________________________________________________________

4. Gender :_____________________________________________________________

5. Occupation - Employer :_____________________________________________________________

- Position :_____________________________________________________________

6. Permanent Address :_____________________________________________________________

_____________________________________________________________

______________________ Postcode : ___________________________

7. Correspondence Address :_____________________________________________________________ _____________________________________________________________

______________________ Postcode : ___________________________

8. E-mail Address :_____________________________________________________________

9. Telephone No : (H/P)______________________ (Res) ___________________________

(Off) _______________________ ext ___________________________

I offer myself for admission to membership of the Co-operative Society and enclosed herewith the sum of:

1) Entrance Fee RM 20.00

2) Shares subscription RM

3) Total RM

Payment : By Cash [ ] By Cheque No.

* Minimum subscription one hundred (100) shares @RM1.00 per share. All cheques should crossed “Account Payee” and made payable to KOPERASI BUDDHISME MALAYSIA BERHAD / Current Account No: 3072 900 736 (Public Bank) Please do not send cash through the mail. Signature : _________________________ Date : ________________________________

MEMBERS DECLARATION Declaration made in accordance to requirement under the Society’s by-laws 13 and regulation 10 of the

Co-operative Societies Regulation 1995 DECLARATION

To, The Board of Directors Koperasi Buddhisme Malaysia Berhad (Malaysian Buddhist Co-operative Society Limited)

I declare, that I am not mentally disabled;

I declare, that I am not an undischarged bankrupt;

I declare, that I am not a person whom a conviction stands for a registerable offence;

I declare, that I have not been expelled from membership under this Act whereby a period of one year has not elapsed from the date of such expulsion;

I undertake, if admitted, that so long as I remain a member of the Society observe all the provisions of the by-laws, rules and regulations of the Society for the time being in force.

I declare that the information provided are accurate summary of all facts relating to myself, profession or business status which influence the acceptance or otherwise of this application.

Signature : ___________________________________________ Name : ___________________________________________ Date : ___________________________________________

KOPERASI BUDDHISME MALAYSIA BERHAD (MALAYSIA BUDDHIST CO-OPERATIVE SOCIETY LIMITED)

MEMBER’S NOMINEE

I, hereby agree to name the following person(s) as my nominee(s) who upon my death will inherit my membership, in accordance to the by-laws of the society. No. Name NRIC. No./Birth Cert. No. Relationship % Share 1

2

3

4

Total 100%

Applicant’s signature :_____________________________________________________________ Date :_____________________________________________________________ Remarks: If more than one nominee, membership will automatically be transferred to the first named nominee above WITNESS Signature : (1) ____________________________ (2) ____________________________________ Name : (1) ____________________________ (2) ____________________________________ Date : _______________________________ REPLY SLIP (Please fill for acknowledgement) Mr/ Miss/ Mdm : ___________________________________________________________________

Address : ___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

Your application received on _____________________________________________________________