Al-Hidayah Maslahah
Lifestyle Membership
Scheme
APPLICATION TYPE :   Please select where applicable
INDIVIDUAL
INSTITUTIONAL
INDIVIDUAL PARTICULARS
NAME OF APPLICANT :
(AS PER NRIC/PASSPORT)
NRIC/PASSPORT NUMBER :
DATE OF BIRTH : / /
RACE :
GENDER : MALE FEMALE
MARITIAL STATUS : SINGLE MARRIED
NATIONALITY : MALAYSIAN, BUMIPUTRA MALAYSIAN, NON BUMIPUTRA NON MALAYSIAN
OCCUPATION :
MAILING ADDRESS :
TELEPHONE/HP NUMBER :
EMAIL ADDRESS :
HOUSEHOLD INCOME : RM100,000 & BELOW RM100,000 - RM199,000 RM200,000 & ABOVE
FAMILY PARTICULARS
NAME OF SPOUSE :
NRIC/PASSPORT NUMBER :
DATE OF BIRTH : / /
OCCUPATION :
NUMBER OF CHILDREN :
TELEPHONE/HP NUMBER :
PARTICULARS OF CHILDREN :
NAME GENDER(M/F) NRIC/PASSPORT NUMBER
MALE
FEMALE
MALE
FEMALE
MALE
FEMALE
MALE
FEMALE
MALE
FEMALE
INSTITUTIONAL PARTICULARS
NAME OF COMPANY :
MAILING ADDRESS :
NATURE OF BUSINESS:
TELEPHONE NUMBER :
EMAIL ADDRESS :
REGISTRATION NUMBER :
DATE OF INCORPORATION :
CONTACT PERSON AND DESIGNITION :
DESIGNATED REPRESENTATIVES :
NAME GENDER(M/F) NRIC/PASSPORT NUMBER
MALE
FEMALE
MALE
FEMALE
MALE
FEMALE
MALE
FEMALE
MALE
FEMALE
MALE
FEMALE
MALE
FEMALE
MALE
FEMALE
MALE
FEMALE
MALE
FEMALE
MALE
FEMALE
MALE
FEMALE
SUBSCRIPTION PARTICULARS
NUMBER OF ISU APPLY :
TOTAL AMOUNT (RM) : , , ,
PAYMENT TYPE : CHEQUE (PAYABLE TO: AL-HIDAYAH LIFESTYLE SCHEME)
BANK-IN / TT (MBB XXXXXX)
CREDIT CARD (2% ADMIN FEES)
INSTALLMENTS
CHEQUE / BANK DRAFT NUMBER :
BANK NAME :
AMOUNT (RM) :
BANK ACCOUNT DETAILS
BANK NAME :
BANK ACCOUNT NUMBER :
OTHERS
PREFERRED LANGUAGE : BAHASA MALAYSIA
ENGLISH
DECLARATION
1)   I/We the undersigned , hereby declare that the particulars given are true to my / our knowledge and belief
2)   I/We agree that if my / our application is successful, Al-Falah Sejati Berhad, will within fourteen (14) days from the date of application inform me / us of the acceptance
3)   I/We agree that in any event my /our application is unsuccessful, any monies paid by me / us shall be refundable to me / us without interest
4)   I/We also agree to pay by instalment of the Subscription price as stipulated in the prospectus on the procedure and payment terms
5)   I/We hereby declare and agree that the declaration set out herein shall be taken , read and construe as an essential part of membership issued to me /us, on the event that my / our application is approved by Al-Falah Sejati Berhad.
6)   I/We the undersigned, hereby give my / our consent to Al-Falah Sejati Berhad to process my / our personal data. By this consent, I/We understand and agreed that Al-Falah Sejati Berhad may conduct reference checks on me /us with any business entity / ies for bona fide trade checking now or any future time for the purpose of opening new account evaluation, review, monitoring, debt recovering purpose and / or legal documentation.
SIGNATURE OF APPLICANT :
DATE :
Please returned completed form to:
Al-Falah Sejati Berhad
Suite 11.01, Menara Hidayah,
Jalan 3/27A, Seksyen 1, Wangsa Maju,
53300 Kuala Lumpur
Tel: 03 - 4142 4780
Fax: 03 4148 1503
FOR OFFICE USE ONLY
INTEREST HOLDER SECTION
DATE APPLICATION RECEIVED :
PAYMENT TYPE :
CHEQUE NUMBER :
AMOUNT :
DATE APPLICATION RECEIVED :
REMARKS :
REMARKS: APPROVED / NOT APPROVED
AGENT NAME :
AGENT CODE :
MANAGER :
DATE :
INTEREST HOLDER NUMBER :