ASSYAKIRIN MOSQUE MANAGEMENT BOARD

REGISTRATION FORM
4th ISLAMIC CIVILISATION TOUR
10D INDIA-KASHMIR
S$2,299 (FULL BOARD)

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recent
passport
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1-10 December 2012

Registration No.

FOR OFFICIAL USE:

PAID/ NOT PAID AMOUNT : $ _________________
*CASH/NETS/CHEQUE NUMBER: __________________
RECEIPT NO:________________ DATE: ________________
NAME OF ISSUING OFFICER: ________________________

Date:

ACCOMPANYING FAMILY MEMBERS : FATHER/MOTHER/ HUSBAND/WIFE/

DAUGHTER/SON/BROTHER/SISTER
Total No:

* please fill up a separate form for each participant

REQUIRED COPIES OF THE FOLLOWING DOCUMENTS:

NRIC/BC & PASSPORT

MEDICAL HISTORY:

MEDICAL RECORDS/ PRESCRIPTIONS

1. ________________________________________

PARENTAL/GUARDIAN LETTER OF CONSENT (FOR INDIVIDUALS BELOW 21)

DIETARY/ALLERY NOTIFICATIONS
VACCINATION: MENINGITIS / INFLUENZA

2. ________________________________________

NAME (AS PRINTED IN PASSPORT):

ADDRESS:

OCCUPATION: ______________________________________

TEL:

( H ) ____________________

__________________________________________________

( O ) ____________________

EMAIL: ________________________________________

H / P ____________________

DATE OF BIRTH:

NRIC NO.

AGE:
PLACE OF BIRTH :

NATIONALITY:

INTERNATIONAL PASSPORT NO:

DATE & PLACE OF ISSUE
PASSPORT EXPIRY DATE
* IN CASE OF EMERGENCY, PLEASE CONTACT
NAME OF NEXT OF KIN

1)
2)

RELATIONSHIP

CONTACT NUMBER