Agent's Application Form

Important: All information requested must be completed Accurately. Otherwise State 'N.A.' Where 'not applicable'. Please write clearly. An incomplete or inaccurate form will not be accepted and will be returned for completion or amendment.

Agent Information

IC No
IC No. (NEW)
(Where old ID No is available, please give both new and old IC numbers)
Salutation
Name
Allias (if any)
Short Name
For Agency Manager/Unit Manager - Determination of Agency Structure
Mobile no. +60
Email address
EPF No:
Socso No:
Upload Passport Photo:-
Upload Document:-
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