MEMBERSHIP APPLICATION FORM

Please fill in the form and submit it upon completion.


Provisional/Ordinary/Affiliate

Associate

Fellow

Life

Provisional: RM10 for 1st time application , once in a lifetime.

Ordinary: RM100/ year

Affiliate: RM100/ year

Associate: RM150/ year

Fellow: RM200/ year

Lifetime: lump sum payment of RM3,000 subject to approval by NAMLIFA

PERSONAL DETAILS

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COMPANY DETAILS

PAYMENTS

1. Cash / Cheque Payment
Enclose Payment RM
by Cash / Cheque No.
(payable to NAMLIFA) (NAMLIFA Account: Hong Leong: 2810 0000 380, kindly provide bank in slip)
2. Credit Card Payment
3. Company Deduction (Auto Deduction/Renewal) [Except: AIA, AXA Affin, Manulife, Prudential & Takaful Agents)
I,
declare all the above information is correct at the time of application and I hereby authorise
(Company) to debit RM
payable to
NAMLIFA from my commision as per my Agent Code or Account No:
, on an Annual Basis.
Receipt

I understand that membership fees paid are non-refundable.

Sign in the box below.

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TERMS AND CONDITIONS

Terms and Conditions
Registration of membership will only be processed upon the following:-
- successful clearance of cheques.
- successful swiping of credit cards.
- successful clearance of company deduction.

By signing this form, I hereby give consent to NAMLIFA to auto-renew my membership annually. Any request for termination of membership, will need to be made in writing.

For company deduction, kindly allow 30 - 40 days of processing time.

Membership fees paid are non - refundable.

I agree that my signing on the NAMLIFA membership form shall constitute my acceptance of and my agreement to be bound by the terms and conditions contained in this form.

Sign in the box below.

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