MEMBERSHIP CARD APPLICATION FORM 会员卡申请表格
NAME (FULL NAME AS IN NRIC) 英文姓名 *
TITLE 称呼 *
GENDER 性别 *
DATE OF BIRTH 出生日期 *
MM
/
DD
/
YYYY
I.C. NO / PASSPORT NO 身份证号码/护照号码 *
NATIONALITY 国籍 *
CONTACT NO. 联络号码 *
MAILING ADDRESS 邮寄地址 *
EMAIL ADDRESS 电子邮件
Where would you like to collect your physical membership card? 会员卡领取分行 *
By submitting this form, you hereby acknowledge that you have read and agree to the terms and conditions stated in AM PM Pharmacy website.
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