Borang Ran Ahli Kariah(1)

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BORANG PENDAFTARAN ANAK KARIAH MASJID/ SURAU SELURUH NEGERI SELANGOR

Kariah Masjid/ Surau:

………………………………………………………………………………………………….

BAHAGIAN A: BUTIRAN ANAK KARIAH 1. Nama Pemohon 2. No. Kad Pegenalan

(Sertakan salinan kad pengenalan)

3. Alamat Dalam Kad Pengenalan/ Passport

4. Alamat Tempat Tinggal Sekarang

5. No. Telefon Rumah 6. Status Perkahwinan

H/P Bujang

7. Tempoh Masa Telah Menetap Adalah

Sudah Berkahwin Tahun/ Bulan

BAHAGIAN B: PERAKUAN PENGESAHAN ANAK KARIAH Ulasan Nazir/ Setiausaha Masjid/ Surau: ………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………

………………………………. T/ Tangan Nazir/ Pengerusi Masjid/ Surau Cop Rasmi Ulasan Ketua Kampung/ Pengerusi JKKK/ Majlis Perwakilan Penduduk/ Pengerusi Jawatankuasa Penduduk: ………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………

………………………………. T/ Tangan Cop Rasmi

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