APPLICATION FORM TO JOIN THE REGIONAL NETWORK COMMITTEE Personal Details Name: (in full): _________________________________________________________ Please print in block letters Date of Birth: _____/_____/ _______ CIMA Contact ID number:___________________ (optional) DD MM YEAR Designation: ___________________________________________________________ Company: ____________________________________________________________ Please (√) one region based on your residing state: Central Southern Northern East Malaysia Kuala Lumpur, Selangor and Pahang Johor, Melaka and Negeri Sembilan Perlis, Perak, Pulau Pinang, Kedah, Kelantan and Terengganu Sabah and Sarawak Application form, resume and e-photo Please attach a copy of your resume which should be no longer than 200 words together with the application form. Applicant also required to send an up-to-date e-photo (Jpeg or Tif). Declaration I ______________________________________________, the undersigned being a member of the Chartered Institute of Management Accountants hereby confirm the foregoing particulars are correct and declare that I consent to be a committee member of the regional network and that I undertake to promote the interests of the Institute to the best of my ability. Signature:____________________________ Date: __________________________ Note: Kindly take note that an election will be conducted electronically if we receive applications that exceed the maximum number required. Elections for the posts of Chairman, Deputy Chairman, Secretary and Treasurer of the regional network will also be conducted electronically.