MEMBERSHIP FORM

NEW APPLICATION
RENEWAL
PERSONAL DETAILS
1. FULL NAME:

2. FACEBOOK NAME:
3. NRIC:

4. DATE OF BIRTH:
D D
M M
Y Y Y Y

6. GENDER:
MALE

5. AGE:
YEARS

7. TELEPHONE NUMBER:
FEMALE

8. ADDRESS:

9. STATE:

10. POSTCODE:

11. NATIONALITY

CAR DETAILS
12. CAR REGISTRATION NUMBER:

13. LAST 6 DIGITS OF CHASSIS NUMBER:

14. COLOUR:
BLACK

15. VARIANT:
CFE CVT

RED

WHITE

SILVER

BROWN

LILAC

BLUE

IAFM CVT

IAFM MANUAL

I hereby declare that the information given in this application is true and correct.
If I am accepted as a member, the information shall form part of the agreement and I agree to be bound by the
Terms & Conditions of Membership.
I hereby authorise Prevoc to contact me via the mobile number given above with regard to my Prevoc
membership application.

DATE:

D D

M M

Y Y Y Y

SIGNATURE:
FOR ADMINISTRATION USE

PAYMENT MADE:
PAYMENT DATE:
PAYMENT METHOD:

YES

NO

D D

M M

Y Y Y Y

INTERNET BANKING
ATM

LAST AMENDED: 19/5/2015

PREVOC ID:

REMARKS:

CASH

PREVOC MEMBERSHIP APPLICATION FORM V.3.1

PPM-016-14-11072012