My Pharmacy Membership Program
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Member Form
Please fill up this form in CAPITAL LETTERS 请以英文大字母填写
Name (Full name as in NRIC) 姓名 *
Your answer
IC No. 身份证号码 *
Your answer
Date Of Birth 生日日期 *
MM
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DD
/
YYYY
Marital Status 婚姻状况 *
Nationality 国籍 *
Address 地址 *
Your answer
Town 城市 *
Your answer
State 州府 *
Your answer
Postcode 邮区号码 *
Your answer
Contact No 联络号码 *
Your answer
Email Address 电邮地址 *
Your answer
Household Size 家庭人数 *
Your answer
Household Income 家庭入息 *
Language 语言 *
Terms and Conditions
I declare that the data provided is correct and accordingly, if this application is accepted. I accept and agree to the Terms and Conditions of My Card Membership Program. I declare that all individuals who are the subject of any personal data provided herein have consented to my disclosure of the personal data to My Pharmacy Group and its affiliates and to the use by My Pharmacy Group and its affiliates of the personal data accordance with the policy on personal data of My Pharmacy Group. My Pharmacy Group and it affiliates and/or its business partner wish to use the contact details provided in this application form to send you information about others good and/or services they offer which may be of interested.
I hereby agree to abide Terms and Conditions of My Card Membership Program *
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