Please print out the form, fill it up and mail or fax it to us OR email us. If the email link doesn't work, please email the form to nci@alum.mit.edu.

MEMBERSHIP APPLICATION FORM
Name: I.C./Passport No.:
Date of Birth: Place of Birth:
Correspondence Address:
Residential Address:
Telephone(Home or H/p): Telephone(Office):
Fax Number: Email address:
Occupation / Designation:
Employer / Organization:
Address of Employer:
MIT Experience
Course / Program / Degree / Year:
Other MIT Experience / qualifications:
Non-MIT Experience / qualifications:

I would like to join the MIT Club of Malaysia as a life * ordinary / associate member. I attach a cheque for the Life Membership Fee of RM250, payable to "MIT Club of Malaysia"

The committee reserves the discretion to decline or to accept any membership application and not to give any reason for doing so.

I agree to be bound by the constitution and rules of the MIT Club of Malaysia, as may be amended from time to time.
Date: ____________________________ Signature: ____________________________