Registration Form Alumni SAMURA
Please make a payment prior filling-out the form. If you wish to make a donation to Alumni, please include in the payment as well.
Email address *
ALUMNI'S BANK ACC NO
551632000906
MAYBANK
PERSATUAN ALUMNI SEK MEN SAINS MUAR JOHOR
MEMBERSHIP *
PROVE OF PAYMENT (RECEIPT)
Donation (if any to support alumni's activities)
This could be included in the membership fee payment.
EX-STUDENT / EX-STAFF *
SRP / SPM / STPM or LEAVING YEAR *
NAME *
TITLE *
I/C NO. *
GENDER *
DATE OF BIRTH *
MM
/
DD
/
YYYY
OCCUPATION *
HOME ADDRESS *
TEL. NO. (HOME)
Please start with country code e.g. 607-xxxxxxx
TEL. NO (MOBILE) *
Please start with country code e.g. 601-91234567
COMPANY NAME
COMPANY ADDRESS
DECLARATION
I hereby confirm that I was a student / staff of Sekolah Menengah Sains Muar, Johor. I also confirm that all the information given above is correct and complete. On admission, I agreed to abide by the rules and regulation set out in the Alumni SAMURA’s constitution.
A copy of your responses will be emailed to the address you provided.
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