SOUND AND SOLID INVESTMENT

PUBLIC FINE GOLD INTERNATIONAL SDN. BHD.(818840-U)

AGENT REGISTRATION FORM

PERSONAL INFORMATION
Name of Member (English) Mr. / Mrs. / Name of Introducer Introducer’s
Miss ROMAIZAT BIN Registration
MOHD NASIR A0702

Chinese Name Date of Birth

I.C. /Passport No. Nationality

Occupation (Or Type of Business) Year(s) Employed

Name of Employer (If self-employed, name of business)

Business Address

Residential Address

Residential Phone Business Phone Mobile Phone Facsimile No.

Email Address

Communication Method (for Notices)

Post to Residential Address Post to Business

Address

Payment Method (for fund withdrawal)

Deposit in Bank (Please complete the bank details in the next section)

Internet Transfer (By using same bank)

Telegraphic Transfer (By using same bank. Charges shall be borne by the account
holder)

Cheque (With condition cash deposit 10%)

Bank Details (Maybank or Public Bank)
Name of Bank Account Holder

Name of Bank Account No.

Account Type

Saving Account Current Account

Applicant Declaration
I hereby declare that the information given above is true, accurate and complete. I
understand that Public Fine Gold International Sdn Bhd has the right to reject my
application without assigning any reason thereof. In the event of my application has being
approved, I hereby undertake and agree to be bound in all respects by the company’s
regulation.

____________________ __________________________
________________________
Date (dd/mm/yy) Name of Applicant
Signature of Applicant

After complete, fax this form to Public Gold office at 04-6464916

For Office Use Only

Checked by: ___________________________________________Signature:

_____________________________

Remarks :
___________________________________________________________________________________

________________________________________________________________________________
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Customer Registration No. :_________________________

Sponsored by (Customer Registration No.) :

______________________________________________________

Approved by: ____________________________________ Date :

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