Please complete the following particulars and send to us for our processing.
ABOUT YOURSELF
Mr Mrs Miss Ms Mdm Dr Surname/Name
Current Home Address
Nationality S'porean M'sian PR Foreigner Others NRIC No.
Date of Birth -- dd/mm/yy Marital Status Single Married Divorced Widow
Home Tel Pager Handphone
Correspondence Address (if differs from above)
ABOUT YOUR WORK PLACE
Name of Company
Office Address
Nature of Business
Position
Self-Employed No Yes
Office Tel No Ext
Direct Tel Fax No
YOUR OTHER REFERENCE
Do you own a car? Yes No Vehicle No. Name of Insurance Company Manu Year Regn Date -- dd/mm/yy Model CC
How do you know about our membership?
Friend Relative Family Customer Advertisement Others
Do you have any interest or enquiry on the insurance products? If yes, please specify the product which interest you.
I am making payment for my application by VISA CARD MASTERCARD Cheque Money Order
Credit Card No. Expiry Date -- dd/mm/yy
I hereby accept and agree to abide by the terms and conditions governing the issue of the LQ PREMIERE CUSTOMER CLUB INTERNATIONAL CARD.
I understand that LQ ALLIANCE PTE LTD reserves the right to change the conditions without any prior notification.
I note that the Card will be mailed to me and the processing of the Card will take 1 - 2 weeks from the date of the application and that the Card will be renewed upon payment of the required fees by the Card member.