緊急連絡先届

To：The Secretary General
THE JAPAN CLUB OF KUALA LUMPUR,
No.2 Jalan 1/86,Off Jalan Taman Seputeh, 58000 Kuala Lumpur.
日本の緊急連絡先－新規・変更
EMERGENCY CONTACT PERSON IN MALAYSIA/YOUR HOME COUNTRY – NEW / UPDATE
■ 日本人会員用
会員番号：
____________________
会員氏名：_________________________________
連絡先氏名：（和文） ________________________（英文）___________________________
住所：
_____________________________________________________________________
Email：______________________________________ 続柄：__________________________
自宅電話番号：________________________ 携帯電話番号：_________________________
届出日：_________________________ 申請者サイン：_____________________________
■ FOR NON-JAPANESE MEMBERS
Membership No. ___________________ Member’s Name: ___________________________
Name of Contact Person (as in Passport/NRIC): _______________________________________
(For Malaysian, Individual not staying with you)
Address: ______________________________________________________________________
______________________________________________________________________________
Email: _______________________________________Relationship: ______________________
Home Tel No.: ___________________________ Mobile No.: ____________________________
Date of Submission: _____________________ Applicant’s signature: ______________________
＊FOR OFFICE USE ONLY
MEMBERSHIP
RECEIVED DATE
(20150303)

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