COMMUNITY POLICING MALAYSIA

2 keping gambar
berukuran pasport

(Program Kepolisan Komuniti Malaysia)

C/O: No.27-2, Jalan PU 7/4, Taman Puchong Utama,
47140 Puchong, Selangor Darul Ehsan.
Tel: 03-8061 2044
Fax: 03-8068 5444
BORANG PENDAFTARAN
REGISTRATION FORM
Lamanweb: www.cops.org.my

Facebook: cops.org.my
Email: kuan@cops.org.my

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passport size photo
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Sila lengkapkan semua bahagian borang dengan menggunakan HURUF BESAR dan tandakan ( ) di kotak yang sesuai. Please complete all sections
of the form in BLOCK LETTERS and tick ( ) in the appropriate boxes. ( )
Saya memohon menjadi Ahli Program Kepolisan Komuniti Malaysia dan butir-butir peribadi saya adalah dicatitkan seperti di bawah. I would like to
be a member of Community Policing Malaysia and my particulars are as follows.
1. Nama Cina (jika ada) / Chinese Name / (): ________________

**Maklumat WAJIB / Compulsory Details/

2. Nama Penuh mengikut Kad Pengenalan / Full Name as in NRIC / **

3. No. Kad Pengenalan Baru / New I/C No. / **

5. Tarikh Lahir / Birth Date / **

4. Negeri Lahir / Birth State / **

6. Umur / Age / **

7. Jantina / Gender / **

L/M/

P/F/

8. Pekerjaan / Occupation / **

9. Alamat Semasa / Current Address / **

10. No. Telefon Rumah / Home Phone No. /

11. No. Telefon Bimbit / Handphone No. / **

**Type [ON >space< CP] send SMS to 33555 for receive crime/CP info

12. Alamat E-mel / E-mail Address /

13. Balai Polis Berhampiran / Nearest Police Station /

14. Daerah Polis / Police District /

i) Kad ID/ ID Card / :

Ahli Biasa/Ordinary Member/

RM50

EXCO/EXCO/ RM130

ii) Lencana/Badge/:

Ahli Biasa/Ordinary Member/

RM10

EXCO/EXCO/ RM15

iii) Baju Korporat/Corporate Shirt/

[size: S / M / L / XL / XXL] RM70

iv) Baju Polo T/Polo T-Shirt/

[size: S / M / L / XL / XXL] RM40

ix) Topi/Cap/

RM20

x) Sijil/Certificate/ RM10

v) Baju Kolar Bulat/Roundneck T-Shirt/ [size: S / M / L / XL / XXL] RM28

vi) Peti Lawatan CP/CP Visitation Box/

RM60

vii) Insurans Kemalangan Diri/P.A.Insurance/ RM20

xi) Pelekat Cermin/Windscreen Sticker/ RM10

xii) Pelekat CP/CP Sticker/ CP

RM5

viii) SOS Bantuan Komuniti/SOS Community Assistance/SOS RM50

**Tandatangan Pemohon / Applicants Signatory / : ___________________________

Tarikh / Date / : _______________

Disokong Oleh / Seconded By / : _________________________________ No. Tel/ Handphone No./ : __________________

UNTUK KEGUNAAN PEJABAT / For Office Use /

Kod ID / ID Code / :

Daerah (IPD) / Negeri :

_____________________________
Tandatangan Pengurusan /
Authorized Signatory /

Mei 2015