No.12345

Activity Type (please underline relevant info)

Occupation HQ / Branch / Rep Office / Distributor / …

Local Production (please underline relevant info)

Yes / No

Mobile No

Nationality

Mobile No

Contact Email

Age

PERSONAL INFORMATION

Date of Birth

GENERAL INFORMATION

Name Gender (F/M)

INFORMATION ON KIDS (optional)

INFORMATION ON PARTNER (optional)

First Name

Last Name

Contact Email

Contact No

Contact Email

Permanent Address

Malaysia-Belgium-Luxembourg Business Council (222068-H)

Tel: +603 4108 1282 x 116 Fax: +603 4108 1262Email: info@mblbc.org

DPO House, B2-G, Lorong Selangorc/o DPO International Sdn Bhd

Pusat Komersial Gaya, Pusat Bandar Melawati53100, Kuala Lumpur, Malaysia

No of Belgians Employed in your Malaysian Company

MBLBC MEMBERSHIP APPLICATION FORM

Company Website

Title

Business in Mal. since (dd/mm/yy)

Tel No

First Name

Last Name

Company Name

Company Address

Tel No Fax No

Nationality

Title

Products / Services Offered

Director

No. Mobile12

1

2

34

1 Cheque

Cheque No

Amount

2 Cash Amount

Ref: 01012020-MBLBC

Cheque payable to "Malaysia Belgium Luxembourg Business Council"

……………………………………………………………………………………………………………….

DPO House, B2-G, Lorong SelangorPusat Komersial GayaPusat Bandar Melawati53100 Kuala Lumpur, MalaysiaAttn: Mrs Teffeny Chang (Tel: 03-41081282)

Name

Date

Kindly forward cheque to MBLBC Secretariat :MBLBCc/o DPO International Sdn Bhd

PAYMENTI wish to make payment by :

CORPORATE MEMBERSHIP ONLY (Name of employees eligble in the same corporate membership, max 2 additional)

TYPE OF MEBERSHIP (please tick in relevant column)

Corporate Member (RM 800)

DISCLOSURE OF INFORMATIONThis information is for internal mailing purpose only as well as to understand better the needs of the Belux community in Malaysia. Should any 3rd party ask for this information, permission from the respective members will first be raised.

Active Member Regular Member

Designation

PREFRENCE OF ROLE IN COUNCIL (please tick in relevant column)

E-mailName

"0" cost for upgrade of memberships

GENERAL NOTES ON MEMBERSHIPEach yearly subscription fee shall be payable on Jan 1st of every year. The validity for each membership is 12 months. Memberships applied in the middle of the year will be charged pro-rata of the balance-period in the calendar-year. There will be no-refund for members who chose to cancel their membership before the end of the calendar-year, including for reasons of leaving the country. Memberships can however be transfered to a different individual within the same organisation.

A downgrade of membership is feasible but it is subject to an administration cost of RM 100.

MBLBC SECRETARIAT ONLY

SIGNATURE

MBLBC Membership No

Approval by BOD

Membership Card No Date

Independent Member (RM300)

For members who fail to pay their subcription fee within 3 months of its due date (Mar 31st ), their membership will automatically be terminated. If they want to resume their membership after it is terminated, a penalty of RM 300 will be imposed.