Arahan/Instruction:Sila lengkapkan dan kembalikan ke alamat seperti di bawah. Anda akan menerima kad keahlian anda dalam tempoh satu ke dua bulan

Please complete and return to the address below. You will receive your membership card within one to two months

Maklumat Peribadi / Personal Information

Nama/ Name:

Gelaran/ Title:

No. Kad Pengenalan/ IC No.:

Jantina/Gender :

Tarikh Lahir/ D.O.B.:

Status Perkahwinan/ Marital Status:

Kolej

Latar Belakang Pendidikan Di UPM/ Education Background in UPM

Item Program/ Programme Fakulti/ Faculty Tahun/ Year

Diploma

Bacelor

Master

PhD

* Sila sertakan satu salinan sijil pengajian terkini di UPM / Please enclose a copy of the current education certificate in UPM

Alamat Tetap/ Permanent Address

Poskod/ Postcode :

Daerah/ District :

Negeri/ State:

Pekerjaan/ Profession

Organisasi /Organisation :

Jawatan/ Position:

Alamat/Address

No. Tel /Tel. No: No. Tel Bimbit /HP No. :

E-mel / E-mail: No. Faks/ Fax No. :

Alamat Perhubungan/ Contact Address

Alamat Tetap/ Permanent Address

Alamat Organisasi/ Organisation Address

Borang KeahlianMembership Form

Keahlian / Membership

Ahli Seumur Hidup / Life Member (Alumni UPM/ UPM Alumni) • RM50.00

Ahli Bersekutu / Associate Member (Staf UPM/ UPM’s Staff) • RM50 / Tahun / Year

Cetak Semula / Reprint • RM10

Kaedah Pembayaran / Payment Method

Cek / Cheque No. Cek / Cheque No.

Wang Pos / Postal Order Nombor / Number

Cek/ kiriman wang boleh dibayar atas nama “Persatuan Alumni UPM” No Akaun CIMB 8002150285Cheque/ postal order payable to “Persatuan Alumni UPM” CIMB Account No. 8002150285

Untuk Kegunaan Pejabat / For Offi ce UsePermohonan diluluskan / Application approved, Tidak diluluskan / Not Approved

Tarikh diluluskan / Approve date : ______________________ No. Keahlian / Membership number : _______________________

*Sila Sertakan bersama “Business Card” anda.

*Please attach your Business Card.

Persatuan Alumni UPM (PAUPM)Aras Bawah, Bangunan Canselori Putra, Off Lebuh SilikonUPM Serdang 43400 Serdang SelangorT : 03 8946 7242/ 7243/ 7244E : alumniupm@gmail.comW : http://www.alumniupm.my

Tunal / Cash Tandatangan / Signature